INQ0017990 – Page 458 of Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995, dated July 2001
Publication Date:
7 January 2025
INQ0107810 – Pages 1 and 7 of the Code of Conduct for NHS Managers, dated October 2002
Source Date:
1 October 2002
Publication Date:
7 January 2025
INQ0013046- Document titled Memorandum of Understanding regarding investigation into patient safety incidents involving unexpected death or serious untoward harm, dated February 2006
Source Date:
1 February 2006
Publication Date:
10 January 2025
INQ0107019 – Pages 1, 4, 8 -10, 15 and 24 of Guidance from the Department of Health titled Guidelines for the NHS in support of the Memorandum of Understanding, Investigating patient safety incidents involving unexpected death or serious untoward harm: a protocol for liaison and effective communications between the National Service, Association of Chief Police Officers and the Health & Safety Executive, dated November 2006
Source Date:
1 November 2006
Publication Date:
15 January 2025
INQ0011612 – Exhibit SD/06 – Document titled Practice Directions for Doctors, authored by Mr Rheinberg, updated March 2009
Publication Date:
20 January 2025
INQ0008961 – Pages 1, 23, 45, 47 and 49 of bundle of documents relating to Letby’s HR file, dated between 16/01/2012 and 04/2016
Source Date:
16 January 2012
Publication Date:
5 November 2024
INQ0017175 – Report from The Council for Healthcare Regulatory Excellence titled Standards for members of NHS boards and Clinical Commissioning Group governing bodies in England – Advice to the Secretary of State for Health, dated May 2012
Publication Date:
7 January 2025
INQ0002879 – Pages 3, 99 and 100 of bundle of documents relating to Letby’s grievance file, dated between 01/01/2013 and 07/09/2016
Source Date:
1 January 2013
Publication Date:
5 November 2024
INQ0108020 – Pages 151 – 155 and 160 of Report from the Royal College of Paediatrics and Child Health titled Child Protection Companion 2013, regarding safeguarding children, dated May 2013
Publication Date:
26 September 2024
INQ0108339 – Pages 1 – 2 and 5 – 6 of Presentation titled Safeguarding Children Training Group 3, dated June 2013
Publication Date:
18 November 2024
INQ0002639 – Page 1 of the Quality, Safety & Patient Experience Committee’s Terms of Reference, dated 17/06/2013
Publication Date:
16 October 2024
INQ0011613 – Exhibit SD/07 – Document titled Reporting Deaths to the Coroner, dated July 2013
Publication Date:
20 January 2025
INQ0014469 – Page 1 of datix incident report form detailing a dosage error to a non-ciphered child on the neonatal unit, dated 22/07/2013
Publication Date:
16 October 2024
INQ0008961 – One to One Form from the Countess of Chester Hospital recording feedback to Letby, dated 23/07/2013
Publication Date:
16 October 2024
INQ0012033 – Page 171 of messages between Letby and Ruth Sadik, dated 01/08/2013
Source Date:
1 August 2013
Publication Date:
16 October 2024
INQ0012033 – Page 171 of messages between Letby and Ruth Sadik, dated 01/08/2013
Source Date:
1 August 2013
Publication Date:
17 October 2024
INQ0106967 – Pages 3 and 6 – 8 of Policy from NHS Wales titled Procedural Response to Unexpected Deaths in Childhood (PRUDiC) 2014, dated 25/02/2014
Source Date:
25 February 2014
Publication Date:
26 September 2024
INQ0102686 – Pages 1 and 18 of Guidance from the Royal College of Nursing, titled Safeguarding for children and young people – every nurse’s responsibility, dated 08/04/2014
Publication Date:
13 January 2025
INQ0002594 – Operational Management Structure for the Urgent Care Division, dated 15/01/2015
Source Date:
15 January 2015
Publication Date:
21 October 2024
INQ0004511 – Pages 1 – 3 of Document titled Clinical Risk Assessment, completed by Eirian Powell, dated 18/02/2015
Source Date:
18 February 2015
Publication Date:
17 October 2024
INQ0013235 – Report from Department of Education titled Working Together to Safeguard Children – A guide to inter-agency working to safeguard and promote the welfare of children, dated March 2015
Publication Date:
26 September 2024
INQ0014575 – Page 91 of Guidance titled Working Together to Safeguard Children, dated 01/03/2015
Publication Date:
13 November 2024
INQ0108796 – Page 5 of Report from NHS Employer titled Pay and Conditions Circular (M&D), dated 20/03/2015
Source Date:
20 March 2015
Publication Date:
22 January 2025
INQ0009236 – Page 13 of Document from NHS England titled Serious Incident Framework, dated 27/03/2015
Source Date:
27 March 2015
Publication Date:
22 October 2024
INQ0009236 – Pages 1, 13 – 15 and 34 of Report from NHS England Patient Safety Domain titled Serious Incident Framework, dated 27/03/2015
Source Date:
27 March 2015
Publication Date:
17 January 2025
INQ0014580 - Page 3 of Pan-Cheshire Guidelines for The Management of Sudden Unexpected Death in Infants and Children (SUDIC), dated 01/04/2015.
Publication Date:
12 September 2025
INQ0108344 – Page 1 and 74 of Training Presentation from Dr Howie Isaac and Paula Lewis titled Safeguarding Children Group 2 Training, dated 04/05/2015
Publication Date:
18 November 2024
INQ0106981 – Draft Terms of Reference for Regional Quality Surveillance Group, prepared by NHS England North Region, dated 07/05/2015
Publication Date:
16 January 2025
INQ0107822 – Letter from Jane Evans to Alison Kelly, dated 14/05/2015
Publication Date:
8 January 2025
INQ0000698 – Pages 28 – 29 of Medical Records of [Child B], dated 07/06/2015
Publication Date:
19 November 2024
INQ0002042 - Page 4 of medical records of [Child A].
Publication Date:
10 September 2025
INQ0000698 – Pages 25, 26, 28 – 29 of Medical Records of [Child B], dated 09/06/2015
Publication Date:
7 October 2024
INQ0000016 – Pages 1 – 2, 5 – 6 and 8 of Datix Report relating to [Child A], dated 10/06/2015
Publication Date:
22 October 2024
INQ0000698 – Pages 26-28 of Medical Records of [Child B], dated between 09/06/2015 and 10/06/2015
Publication Date:
9 September 2025
INQ0000101 – Pages 1 – 2 and 6 – 8 of Letby’s messages with a number of colleagues on the neonatal unit, dated between 12/06/2015 and 13/06/2015
Publication Date:
10 October 2024
INQ0002047 Page 3 to 5 of medical records of [Child C].
Publication Date:
10 September 2025
INQ0000111 – Datix Report of [Child C]. Incident on 14/06/2015.
Publication Date:
18 September 2024
INQ0003229 – Pages 1 – 2 of Datix Management Form for [Child C], dated 14/06/2015
Publication Date:
8 October 2024
INQ0000111 – Page 1 of datix form relating to [Child C], dated 14/06/2015
Publication Date:
16 October 2024
INQ0000111 – Pages 1 – 2 of Datix Report relating to [Child C], dated 15/06/2015
Publication Date:
22 October 2024
INQ0107706 – Pages 55-59 – Terms of Reference of the Corporate Director’s Group, dated 17/06/2015; Terms of Reference of the Finance and Integrated Governance Committee, dated March 2016.
Publication Date:
29 January 2025
INQ0004235 – Pages 2 – 3 of Minutes of the Women & Children’s Care Governance Board meeting, dated 18/06/2015
Publication Date:
8 October 2024
INQ0004235 – Pages 1 and 3 of Minutes of the Women & Children’s Care Governance Board meeting, dated 18/06/2015
Publication Date:
16 October 2024
INQ0004235 – Page 3 of Minutes of the Women & Children’s Care Governance Board meeting, regarding Planned and Urgent Care, dated 18/06/2015
Publication Date:
13 November 2024
INQ0015152 – Pages 1 and 7 of Case Review relating to [Child D], dated 20/06/2015
Publication Date:
16 October 2024
INQ0000758 – Pages 2 – 4 of messages between Letby and Nurse T, dated 22/06/2015
Publication Date:
14 October 2024
INQ0002658 – Page 2 of Datix Form relating to Mother D, dated 22/06/2015
Publication Date:
16 October 2024
INQ0003110 – Pages 1 – 2 and 4 of email correspondence between Countess of Chester staff relating to the review of the case notes in relation to the death of [Child D], dated between 22/06/2015 and 23/06/2015
Publication Date:
17 October 2024
INQ0002658 – Pages 1 – 2 of Datix Report relating to Mother D, dated 22/06/2015
Publication Date:
22 October 2024
INQ0003110 – Pages 1, 4 and 6 – 7 of email correspondence between Countess of Chester staff relating to the death of [Child D], dated between 22/06/2015 and 23/06/2015
Publication Date:
22 October 2024
INQ0003110 – Page 1 – 2 of email correspondence between Debbie Peacock, Stephen Brearey and Ravi Jayaram, dated between 22/06/2015 and 23/06/2015 [relating to [Child D]
Publication Date:
13 November 2024
INQ0002045 – Page 8 – Report from Dr Newby relating to [Child D] [dated 22/06/2015]
Publication Date:
6 December 2024
INQ0025743 – Email chain between Stephen Brearey (Consultant Paediatrician, Countess of Chester Hospital), Elizabeth Newby (Consultant Paediatrician, Countess of Chester Hospital) and other colleagues regarding recent deaths and collapses on the Neonatal Unit of [Child A], [Child B], [Child C] and [Child D] and concerns raised by Registrars and Neonatal Nurses, dated 23/06/2015
Publication Date:
1 October 2024
INQ0025743 – Pages 1 and 2 email between consultants entitled “Deaths on neonatal unit”, dated 23/06/2015
Publication Date:
7 October 2024
INQ0025743 – Pages 1 – 2 of email correspondence between Elizabeth Newby, Stephen Brearey and other Countess of Chester colleagues, dated 23/06/2015
Publication Date:
17 October 2024
INQ0000766 – Pages 1 – 2 of Datix Report relating to [Child D], dated 23/06/2015
Publication Date:
22 October 2024
INQ0003294 – Pages 1 – 2 of Report from the Countess of Chester Hospital titled Perinatal Morbidity and Mortality Meeting Record, dated 24/06/2015
Publication Date:
8 October 2024
INQ0008157 – Emails between Ruth Millward and Sarah Harper-Lea, regarding serious incidents and three neonatal deaths, dated 26/06/2015
Publication Date:
4 November 2024
INQ0003144 - Page 2 - 3 of Emails regarding the classification of child death within the serious incident framework, dated 26/06/2015.
Publication Date:
12 September 2025
INQ0003144 – Pages 4 – 5 of Email correspondence sent to Ian Harvey and others, regarding SI Panel 29th June 2015, dated 26/06/2015.
Publication Date:
17 February 2025
INQ0036166 – Minutes of Senior Clinicians Meeting, dated 29/06/2015.
Publication Date:
1 October 2024
INQ0036974 – Pages 1 – 2 of Minutes of a Senior Clinicians Meeting, dated 29/06/2015
Publication Date:
21 October 2024
INQ0036166 – Pages 1 – 2 of minutes of Senior Clinicians Meeting, dated 29/06/2015
Publication Date:
13 November 2024
INQ0107706 – Page 127 – Handwritten notes of Stephen Cross regarding meeting held on 29/06/2015
Publication Date:
17 January 2025
INQ0000101 – Pages 22 – 23 of messages between Letby and Nurse T, dated 30/06/2015
Publication Date:
14 October 2024
INQ0003191 – Pages 2 – 3 of Report by Dr Stephen Brearey titled Summary of cases, dated 01/07/2015
Publication Date:
17 October 2024
INQ0026017 – Pages 1 – 3 of Neonatal Review Report, regarding [Child A], dated 01/07/2015
Publication Date:
17 October 2024
INQ0003191 – Pages 1 – 3 of Document titled Summary of cases, relating to [Child A], [Child C] and [Child D], dated 01/07/2015
Publication Date:
22 October 2024
INQ0008302 – email correspondence from Stephen Brearey to Debbie Peacock, providing a summary of cases relating to [Child A], [Child C] and [Child D], dated 01/07/2015
Publication Date:
22 October 2024
INQ0002042 – Summary of cases document relating to [Child A], dated 01/07/2015
Publication Date:
4 November 2024
INQ0013225 – Pages 1, 3 and 9 of Pan-Cheshire Guidelines for The Management of Sudden Unexpected Death in Infants and Children (SUDIC), dated 01/07/2015
Publication Date:
12 November 2024
INQ0003191 – Page 3 of Summary of cases produced by Stephen Brearey, dated 01/07/2015
Publication Date:
13 November 2024
INQ0005580 – email from Stephen Brearey to Debbie Peacock, dated 01/07/2015
Publication Date:
13 November 2024
INQ0003191 – Pages 1 – 6 of Report by Dr Stephen Brearey titled Summary of cases, including a detailed review of [Child A], [Child C] and [Child D], dated 01/07/2015.
Publication Date:
19 November 2024
INQ0103164 – Page 2 – Email from Dr Brearey entitled “Jan -June NNU”, dated 01/07/2015
Publication Date:
19 November 2024
INQ0003191 – Page 3 of Report by Dr Stephen Brearey titled Summary of cases, including a detailed review of [Child A], [Child C] and [Child D], dated 01/07/2015
Publication Date:
25 November 2024
INQ0003191 – Pages 1 – 3 of Dr Stephen Brearey’s Summary of cases, including a detailed review of [Child A], [Child C] and [Child D], dated 01/07/2015
Publication Date:
28 November 2024
INQ0003530 – Handwritten note titled ‘SUI Review’ relating to the deaths of [Child A], [Child C] and [Child D] [dated 02/07/2015]
Publication Date:
1 October 2024
INQ0000108 – Page 27 of Medical records of [Child C], relating to debriefing on 02/07/2015
Publication Date:
17 October 2024
INQ0005585 – Page 1 of email correspondence between Eirian Powell, Stephen Brearery, Debbie Peacock, Ravi Jayaram and Yvonne Griffiths, dated 02/07/2015
Publication Date:
17 October 2024
INQ0003625 – Email from Alison Kelly to Dr Stephen Brearey, regarding contribution at neonatal/maternity mortality review meeting, dated 02/07/2015
Publication Date:
19 November 2024
INQ0003530 – Page 1 of Handwritten note by Alison Kelly [serious incident review meeting] dated 02/07/2015
Publication Date:
25 November 2024
INQ0010005 – Page 1 of Report titled Neonatal Incidents May to July 2015, dated 10/07/2015
Publication Date:
19 November 2024
INQ0004216 – Pages 1 and 3 – 5 of Minutes of the Extra-Ordinary Board of Directors Meeting, dated 14/07/2015
Publication Date:
13 November 2024
INQ0003211 – Pages 2 and 5 of Minutes of a Quality, Safety & Patient Experience Committee meeting, dated 20/07/2015.
Publication Date:
16 October 2024
INQ0017282 – Pages 1, 3 and 5 of Notes from Paediatric Specialty Meeting, dated 20/07/2015
Publication Date:
21 October 2024
INQ0003297 – Page 1 of Neonatal Mortality Record, relating to [Child C] and [Child D], dated 29/07/2015
Publication Date:
3 October 2024
INQ0002041 - Page 3 of medical records of [Child E].
Source Date:
4 August 2015
Publication Date:
10 September 2025
INQ0000194 – Pages 1 – 2 of Datix Report relating to [Child E], dated 04/08/2015
Source Date:
4 August 2015
Publication Date:
22 October 2024
INQ0000194 – Page 5 of Datix form for [Child E], entries dated between 02/08/2015 and 03/08/2015
Source Date:
2 August 2015
Publication Date:
7 October 2024
INQ0000194 – Page 6 of Datix Report for [Child E], dated 04/08/2015
Source Date:
4 August 2015
Publication Date:
29 August 2025
INQ0002659 – Pages 4 – 5 of Datix Form for [Child E] dated 04/08/2015
Source Date:
4 August 2015
Publication Date:
28 November 2024
INQ0000861 – Screenshot Of Insulin/C-Peptide Results for [Child F], dated 05/08/2015
Source Date:
5 August 2015
Publication Date:
1 October 2024
INQ0000862 – Screenshot of Call Log Information including Advice/Information relating to [Child F], dated 12/08/2015
Source Date:
12 August 2015
Publication Date:
1 October 2024
INQ0012028 – Datix Report in relation to [Child E], dated 13/08/2015
Source Date:
13 August 2015
Publication Date:
9 September 2025
INQ0000844 – Blood Test Results of [Child F] [Insulin]. Produced for the criminal proceedings of R v Letby, dated 13/08/2015
Source Date:
13 August 2015
Publication Date:
1 October 2024
INQ0005592 – Email regarding papers for SI Panel, in relation to [Child E], dated 13/08/2015
Source Date:
13 August 2015
Publication Date:
29 August 2025
INQ0003299 – Page 1 of Draft Report from Obstetric Secondary Review Team (Countess of Chester Hospital), relating to [Child D], dated 28/08/2015
Source Date:
28 August 2015
Publication Date:
16 October 2024
INQ0003299 – Page 2 of Draft Report from the Obstetric Secondary Review Team (Countess of Chester Hospital), in relation to [Child D], dated 28/08/2015
Source Date:
28 August 2015
Publication Date:
29 August 2025
INQ0033765 – Page 10 of Case Review relating to [Child D], dated 28/08/2015
Source Date:
28 August 2015
Publication Date:
17 October 2024
INQ0004520 – Page 1 of Report from the Countess of Chester titled Level 2 Root Cause Analysis Investigation Report, regarding the death of [Child D], dated 28/08/2015
Source Date:
28 August 2015
Publication Date:
22 October 2024
INQ0014204 – Pages 1 – 2 and 8 of Report from the Countess of Chester Hospital titled Level 2 Root Cause Analysis Investigation Report, relating to [Child D], dated 28/08/2015
Source Date:
28 August 2015
Publication Date:
22 October 2024
INQ0002607 – Structure Chart from the Countess of Chester Hospital NHS Foundation Trust titled Committee Structure, dated September 2015.
Source Date:
1 September 2015
Publication Date:
11 September 2024
INQ0003250 – Pages 1 and 33 of Guidance produced by the Countess of Chester Hospital titled Safeguarding and Promoting the Welfare of Children
Source Date:
1 September 2015
Publication Date:
1 October 2024
INQ0003250 - Page 14 of Safeguarding and Promoting the Welfare of Children Policy, dated September 2015.
Source Date:
1 September 2015
Publication Date:
12 September 2025
INQ0014165 – Pages 1 – 2 and 33 of Policy from the Countess of Chester Hospital titled Safeguarding and Promoting the Welfare of Children, dated 01/09/2015
Source Date:
1 September 2015
Publication Date:
13 November 2024
INQ0014165 – Page 33 of Policy from the Countess of Chester Hospital titled Safeguarding and Promoting the Welfare of Children, dated 01/09/2015
Source Date:
1 September 2015
Publication Date:
19 November 2024
INQ0014813 – Pages 4 and 10 of minutes of meeting for Board of Directors, dated 01/09/2015
Source Date:
1 September 2015
Publication Date:
28 November 2024
INQ0002607 – Page 1 of the Countess of Chester Hospital NHS Foundation Trust’s Committee Structure, dated September 2015
Source Date:
1 September 2015
Publication Date:
13 January 2025
INQ0107706 – Pages 60-75 – Email from Tony Chambers Personal Assistant to Stephen Cross and others, enclosing a bundle of documents regarding Executive Director’s Group meeting on 09/09/2015, dated 08/09/2015.
Source Date:
8 September 2015
Publication Date:
29 January 2025
INQ0003200 – Page 3 of Minutes of a meeting between executive directors group, dated 09/09/2015
Source Date:
9 September 2015
Publication Date:
5 November 2024
INQ0005445 – Pages 1 and 2 of neonatal and perinatal morbidity and mortality meeting record, dated 10/09/2015
Source Date:
10 September 2015
Publication Date:
7 October 2024
INQ0005445 – Page 1 of Report from the Countess of Chester Hospital titled Neonatal Perinatal Morbidity and Mortality Meeting Record, relating to [Child D], dated 10/09/2015
Source Date:
10 September 2015
Publication Date:
12 November 2024
INQ0101965 – email correspondence between Yvonne Williams and Dr McPartland, dated 14/09/2015
Source Date:
14 September 2015
Publication Date:
12 November 2024
INQ0101966 – email correspondence between Joanne Davies and Dr McPartland, dated 15/09/2015
Source Date:
15 September 2015
Publication Date:
12 November 2024
INQ0101967 –email correspondence between Dr McPartland and Joanne Davies, dated 15/09/2015
Source Date:
15 September 2015
Publication Date:
12 November 2024
INQ0101968 – email correspondence between Yvonne Williams and Dr McPartland, dated 15/09/2015
Source Date:
15 September 2015
Publication Date:
12 November 2024
INQ0005531 – Pages 1 and 5 of minutes of Cheshire & Merseyside Neonatal Network Clinical Effectiveness Group Meeting, dated 16/09/2015
Source Date:
16 September 2015
Publication Date:
19 November 2024
INQ0008978 – Pages 4 and 5 of letter from Dr John Gibbs (Consultant Paediatrician, Countess of Chester Hospital) to Mother & Father C, regarding [Child C]’s death, dated 24/09/2015
Source Date:
24 September 2015
Publication Date:
1 October 2024
INQ0030106 – Pages 1 and 2 of emails between Eirian Powell, Dr Gibbs and PALS entitled “communications”, dated between 24/09/2015 and 30/09/2015
Source Date:
24 September 2015
Publication Date:
17 October 2024
INQ0000972 – Pages 31 and 38-39 of Medical Records of [Child H], dated between 26/09/2015 and 27/09/2015
Source Date:
27 September 2015
Publication Date:
9 September 2025
INQ0103110 – Emails between Dr John Gibbs (Consultant Paediatrician, Countess of Chester Hospital), Rajiv Mittal (Consultant Paediatrician, Countess of Chester Hospital) and colleagues, regarding neonatal death and the Child Death Overview Panel forms, dated 28/09/2015
Source Date:
28 September 2015
Publication Date:
1 October 2024
INQ0103110 – Page 1 of email correspondence between John Gibbs, Rajiv Mittal and colleagues, regarding neonatal death and the Child Death Overview Panel forms, dated 28/09/2015
Source Date:
28 September 2015
Publication Date:
18 November 2024
INQ0003296 – Pages 1 and 3 of Incident Review regarding [Child E], dated October 2015
Source Date:
1 October 2015
Publication Date:
19 November 2024
INQ0098668 – Action notes from Speak Out Safely meeting, dated 02/10/2015
Source Date:
2 October 2015
Publication Date:
29 January 2025
INQ0107706 – Pages 76-124 – Email from Tony Chambers Personal Assistant to Stephen Cross and others, enclosing a bundle of documents regarding Executive Director’s Group meeting on 07/10/2015, dated 06/10/2015.
Source Date:
6 October 2015
Publication Date:
29 January 2025
INQ0014813 – Countess of Chester Hospital Board of Directors Agenda and Papers, dated 13/10/2015
Source Date:
13 October 2015
Publication Date:
29 August 2025
INQ0000424 – Pages 59 – 61 of messages between Letby and Nurse T, dated 14/10/2015
Source Date:
14 October 2015
Publication Date:
14 October 2024
INQ0004249 – Page 2 of Minutes of the Women & Children’s Care Governance Board, dated 22/10/2015
Source Date:
22 October 2015
Publication Date:
8 October 2024
INQ0003223 – Pages 1 – 2 of Minutes of a meeting of the Women & Children’s Care Governance Board, dated 22/10/2015
Source Date:
22 October 2015
Publication Date:
21 October 2024
INQ0002043 - Page 3 of medical records of [Child I].
Source Date:
23 October 2015
Publication Date:
10 September 2025
INQ0003106 – email correspondence relating to neonatal mortality review document, dated 23/10/2015
Source Date:
23 October 2015
Publication Date:
16 October 2024
INQ0003189 - Table titled Neonatal Mortality 2015 prepared by Eirian Powell, dated 23/10/2015
Source Date:
23 October 2015
Publication Date:
10 September 2025
INQ0005609 – Page 1 of Email from Eirian Powell to Dr Stephen Brearey and colleagues, [relating to the Mortality Review Document], dated 23/10/2015
Source Date:
23 October 2015
Publication Date:
21 October 2024
INQ0000457 – Pages 1 – 3 of Datix Report relating to the death of [Child I], dated 23/10/2015
Source Date:
23 October 2015
Publication Date:
22 October 2024
INQ0040506 – Pages 1 -2 of Datix Report relating to [Child I], dated 23/10/2015
Source Date:
23 October 2015
Publication Date:
22 October 2024
INQ0098317 – Exhibit CNB/01, Email from Christopher Neil Booth to Eirian Lloyd Powell, regarding commending the great team he worked with during a traumatic night shift, dated 23/10/2015.
Source Date:
23 October 2015
Publication Date:
17 February 2025
INQ0006311 – Page 1 of email correspondence from Ravi Jayaram to Stephen Cross, dated 24/10/2015
Source Date:
24 October 2015
Publication Date:
13 November 2024
INQ0003107 – email correspondence relating to neonatal mortality review document, dated 27/10/2015
Source Date:
27 October 2015
Publication Date:
16 October 2024
INQ0003107 – email correspondence from Eirian Powell to Stephen Brearey, relating to the Mortality Review Document, dated 27/10/2015
Source Date:
27 October 2015
Publication Date:
22 October 2024
INQ0003286 – Page 1 of Mortality Review regarding [Child I], dated 31/10/2015
Source Date:
31 October 2015
Publication Date:
19 November 2024
INQ0003222 – Pages 1 – 2 of Report by Dr Sara Bringham, titled Review of neonatal deaths and stillbirths at Countess of Chester Hospital – January 2015 to November 2015, dated November 2015
Source Date:
1 November 2015
Publication Date:
8 October 2024
INQ0003222 – Page 1 of Document titled Review of neonatal deaths and stillbirths at Countess of Chester Hospital – January 2015 to November 2015
Source Date:
1 November 2015
Publication Date:
22 October 2024
INQ0003589 – Report from Dr Sara Brigham titled ‘Review of neonatal deaths and stillbirths at Countess of Chester Hospital – January 2015 to November 2015’, dated November 2015
Source Date:
1 November 2015
Publication Date:
29 January 2025
INQ0042323 – Report titled Review of Neonatal Deaths and Stillbirths at Countess of Chester Hospital – January 2015 to November 2015, dated November 2015
Source Date:
1 November 2015
Publication Date:
29 August 2025
INQ0000429 – Page 1543 of Medical Records for [Child I], dated 03/11/2015 and 09/11/2015
Source Date:
3 November 2015
Publication Date:
10 October 2024
INQ0004271 – Page 1 and 5 of Minutes of the Women & Children’s Care Governance Board, dated 19/11/2015
Source Date:
19 November 2015
Publication Date:
21 October 2024
INQ0003288 – Page 1 of document titled Neonatal Mortality Meeting Record meeting, regarding [Child I] and other minor, dated 26/11/2015
Source Date:
26 November 2015
Publication Date:
1 October 2024
INQ0103121 – Emails between Stephen Brearey and Caroline Travers regarding death of [Child I], dated between 26/11/2015 and 27/11/2015
Source Date:
26 November 2015
Publication Date:
19 November 2024
INQ0003829 – Business Case for Nurse Staffing in the Paediatrics Neonatal Unit, dated December 2015
Source Date:
1 December 2015
Publication Date:
17 October 2024
INQ0003220 – email correspondece regarding the thematic review, dated 02/12/2015
Source Date:
2 December 2015
Publication Date:
16 October 2024
INQ0003220 – Page 1 of Emails between Alison Kelly and Julie Fogarty, regarding thematic review of neonatal deaths for submission to the Quality, Safety & Patient Experience Committee, dated 02/12/2015
Source Date:
2 December 2015
Publication Date:
25 November 2024
INQ0004528 – Query made through the Cheshire and Merseyside Neonatal Network Communication Process in relation to [Child I], dated 10/12/2015
Source Date:
10 December 2015
Publication Date:
16 January 2025
INQ0003204 - Pages 1 and 5-6 of Minutes of a Quality, Safety & Patient Committee Meeting, dated 14/12/2015
Source Date:
14 December 2015
Publication Date:
15 September 2025
INQ0003204 – Pages 1 and 5 of minutes of the meeting held by the Quality, Safety & Patient Experience Committee, dated 14/12/2015
Source Date:
14 December 2015
Publication Date:
2 December 2024
INQ0001065 – Pages 320 and 354 of Medical Records of [Child J], dated between 27/11/2015 and 17/12/2015
Source Date:
17 December 2015
Publication Date:
9 September 2025
INQ0004371 – Page 1 of Minutes of the Women and Children’s Care Governance Board at the Countess of Chester Hospital, dated 18/12/2015
Source Date:
18 December 2015
Publication Date:
16 October 2024
INQ0101422 – Pages 1 and 5 – 6 of CQC pre-inspection document entitled “Children” dated 22/12/2015
Source Date:
22 December 2015
Publication Date:
14 November 2024
INQ0103668 – Pages 1, 7 and 9 of Report from the Care Quality Commission titled Maternity and Gynaecology, dated 22/12/2015
Source Date:
22 December 2015
Publication Date:
14 January 2025
INQ0015141 – Page 1, 3 and 6 of Report by Debbie Peacock titled Women’s & Children’s Care Incident/Trend Analysis Report Quarter 3 2015/2016 1st October – 31st December, dated January 2016
Source Date:
1 January 2016
Publication Date:
22 October 2024
INQ0007947 – Page 6 of Presentation by the Countess of Chester titled Our CQC Journey by Alison Kelly and Ruth Millward, dated January 2016
Source Date:
1 January 2016
Publication Date:
4 November 2024
INQ0012822 – Pages 4 and 8 of RCPCH Invited Reviews Programme Handbook for Reviewers, dated January 2016
Source Date:
1 January 2016
Publication Date:
7 November 2024
INQ0003835 - Staff analysis showing the working hours of nurses at the Countess of Chester Hospital, dated 04/01/2016.
Source Date:
4 January 2016
Publication Date:
10 September 2025
INQ0003376- Handwritten meeting notes, dated 09/01/2016.
Source Date:
9 January 2016
Publication Date:
29 January 2025
INQ0002045 – Page 962 – Letter from HM Senior Coroner to Gamlins Law, dated 11/01/2016
Source Date:
11 January 2016
Publication Date:
6 December 2024
INQ0004293 – Page 2 of Minutes of the Women & Children’s Care Governance Board, dated 14/01/2016
Source Date:
14 January 2016
Publication Date:
8 October 2024
INQ0015284 – Pages 1 – 3 of Minutes of the Paediatric Speciality Meeting, dated 18/01/2016
Source Date:
18 January 2016
Publication Date:
21 October 2024
INQ0003190 – Pages 1 – 4 of Table of details of neonatal mortality from January 2015 to January 2016, dated 19/01/2016
Source Date:
19 January 2016
Publication Date:
7 October 2024
INQ0003190 – Page 1 of table of details of neonatal mortality from January 2015 to January 2016 prepared by Eirian Powell, dated 19/01/2016
Source Date:
19 January 2016
Publication Date:
16 October 2024
INQ0005642 – email correspondence from Eirian Powell to Stephen Brearey, relating to the Mortality Review Document, dated 19/01/2016
Source Date:
19 January 2016
Publication Date:
22 October 2024
INQ0005643 – Emails between Eirian Powell, Stephen Brearey and others, regarding deaths to review, dated between 19/01/2016 and 22/01/2016
Source Date:
19 January 2016
Publication Date:
20 November 2024
INQ0003277 – Page 1 of document titled Neonatal Mortality January 2015 – January 2016, dated 19/01/2016
Source Date:
19 January 2016
Publication Date:
25 November 2024
INQ0005643 – Pages 1 – 2 of email correspondence between Stephen Brearey and other Countess of Chester staff, regading the mortality review, dated 22/01/2016
Source Date:
22 January 2016
Publication Date:
21 October 2024
INQ0005643 – Page 1 of Email between Eirian Powell and Stephen Brearey regarding deaths to review, dated 22/01/2016
Source Date:
22 January 2016
Publication Date:
13 November 2024
INQ0003575 – Pages 1 – 2 of Email correspondence between Ian Harvey and Alison Kelly titled “MBRRACE” dated 25/01/2016 to 12/02/2016
Source Date:
25 January 2016
Publication Date:
28 November 2024
INQ0017868 – Pages 1 and 5 of Action Notes from Corporate Directors Meeting, dated 27/01/2016
Source Date:
27 January 2016
Publication Date:
7 October 2024
INQ0017868 – Pages 1 and 5 of Action Notes of the Corporate Directors’ Group, dated 27/01/2016
Source Date:
27 January 2016
Publication Date:
8 October 2024
INQ0015325 – Pages 1 – 2 of Draft Terms of Reference of the Women & Children’s Care Governance Board (WCCGB), dated February 2016
Source Date:
1 February 2016
Publication Date:
16 October 2024
INQ0009485 – Pages 1, 4 and 30 of Policy titled Safeguarding and Promoting the Welfare of Children, dated February 2016
Source Date:
1 February 2016
Publication Date:
13 January 2025
INQ0002649 – Pages 1 – 4 of Report from Care Quality Commission titled The Countess of Chester Hospital Quality Report, dated February 2016.
Source Date:
1 February 2016
Publication Date:
25 February 2025
INQ0003217 – Document titled Thematic Review of Neonatal Mortality 2015 – Jan 2016, dated 08/02/2016
Source Date:
8 February 2016
Publication Date:
22 October 2024
INQ0003251 - Thematic Review of Neonatal Mortality, dated 08/02/2016.
Source Date:
8 February 2016
Publication Date:
12 September 2025
INQ0102364 – email correspondence between Sarah Harper-Lea and Debbie Peacock, relating to [Child A], dated between 08/02/2016, 09/02/2016 and 22/04/2016
Source Date:
8 February 2016
Publication Date:
4 November 2024
INQ0003251 – Pages 1, 2 and 7 of meeting relating to the Thematic Review, dated 08/02/2016
Source Date:
8 February 2016
Publication Date:
6 November 2024
INQ0003251 – Page 7 of Minutes of meeting relating to Thematic Review of Neonatal Mortality 2015 – Jan 2016, dated 08/02/2016
Source Date:
8 February 2016
Publication Date:
13 November 2024
INQ0103111 – Page 1 of email correspondence between Dr Subhedar and Stephen Brearey, dated between 08/02/2016 and 10/02/2016
Source Date:
8 February 2016
Publication Date:
13 November 2024
INQ0003217 – Page 7 of Draft Thematic Review of Neonatal Mortality 2015 – Jan 2016, dated 08/02/2016
Source Date:
8 February 2016
Publication Date:
19 November 2024
INQ0003217 – Pages 1 and 7 of Thematic Review of Neonatal Mortality 2015 – Jan 2016, dated 08/02/2016
Source Date:
8 February 2016
Publication Date:
20 November 2024
INQ0102684 – Page 215 – email correspondence betweeen Dr Subhedar, Stephen Brearey and others, dated between 08/02/2016 and 10/02/2016
Source Date:
8 February 2016
Publication Date:
20 November 2024
INQ0003400 – Pages 1-7 and 9 of the ‘Thematic Review of Neonatal Mortality 2015- Jan 2016, dated 08/02/2016
Source Date:
8 February 2016
Publication Date:
29 November 2024
INQ0003217 – Pages 1, 7 and 9 of Thematic Review of Neonatal Mortality 2015 – Jan 2016, dated 08/02/2016
Source Date:
8 February 2016
Publication Date:
4 December 2024
INQ0006817 – Report by Countess of Chester Hospital titled Thematic Review of Neonatal Mortality 2015 – Jan 2016, dated 08/02/2016
Source Date:
8 February 2016
Publication Date:
13 May 2025
INQ0015135 – Page 3 of email correspondence regarding the thematic review of still births and neonatal deaths at Countess of Chester Hospital, dated 09/02/2016
Source Date:
9 February 2016
Publication Date:
8 October 2024
INQ0103141 – Email from Sally Goode to Stephen Brearey, regarding Care Quality Commission interview, dated 10/02/2016
Source Date:
10 February 2016
Publication Date:
19 November 2024
INQ0005449 – Minutes of a Neonatal Perinatal Morbidity and Mortality meeting of Countess of Chester Hospital for the period June to November 2015 & January 2016, relating to [Child C], dated 11/02/2016.
Source Date:
11 February 2016
Publication Date:
1 October 2024
INQ0005449 – Page 1 of Neonatal Perinatal Morbidity and Mortality record, relating to non-ciphered child and [Child C], dated 11/02/2016.
Source Date:
11 February 2016
Publication Date:
19 November 2024
INQ0041363 – Pages 1 – 4 of Minutes of the Paediatric Specialty Meeting, dated 15/02/2016
Source Date:
15 February 2016
Publication Date:
21 October 2024
INQ0003140 – Page 1 of email correspondence between Ian Harvey, Stephen Brearey and Ravi Jayaram, dated 15/02/2016
Source Date:
15 February 2016
Publication Date:
13 November 2024
INQ0003140 – Page 1 – 2 of email correspondence between Stephen Brearey and Ian Harvey, dated 15/02/2016
Source Date:
15 February 2016
Publication Date:
14 November 2024
INQ0103249 – Pages 3 -5 of Emails between John Cunningham to Ruth Millward dated 15/02/2016
Source Date:
15 February 2016
Publication Date:
14 November 2024
INQ0003410 – Pages 1 – 2 of Emails entitled “Neonatal mortality” dated 15/02/2016
Source Date:
15 February 2016
Publication Date:
19 November 2024
INQ0038984 – Pages 1 – 2 of Email correspondence between Alison Kelly and Ian Harvey titled “Neonatal mortality” dated 15/02/2016
Source Date:
15 February 2016
Publication Date:
28 November 2024
INQ0003140 – Page 1 of email correspondence between Ian Harvey and Stephen Brearey, entitled ‘Neonatal Mortaility’, dated 15/02/2016
Source Date:
15 February 2016
Publication Date:
29 November 2024
INQ0038966 – Email correspondence between Ian Harvey and Stephern Brearey, entitled ‘Neonatal mortality’, dated 15/02/2016
Source Date:
15 February 2016
Publication Date:
29 November 2024
INQ0017286 – Pages 1, 11, 14, 16 and 35 of Inspection Team Briefing pack from the Care and Quality Commission, regarding the Countess of Chester’s Inspection, dated between 16/02/2016 and 19/02/2016
Source Date:
16 February 2016
Publication Date:
14 November 2024
INQ0103620 – Pages 1, 7, 27 and 34 of CQC Intelligence Presentation dated 16/02/2016
Source Date:
16 February 2016
Publication Date:
14 November 2024
INQ0103620 – Pages 1 and 26 – 27 of Report from the Care Quality Commission titled Countess of Chester Hospital NHS Foundation Trust Intelligence Presentation, dated 16/02/2016
Source Date:
16 February 2016
Publication Date:
14 January 2025
INQ0017339 – Pages 31, 32 and 33 of Care Quality Commission handwritten acute hospital inspection notes for the Countess of Chester Hospital, regarding children and young people services including the neonatal unit, dated between 16/02/2016 and 19/02/2016
Source Date:
16 February 2016
Publication Date:
15 November 2024
INQ0017339 – Pages 164, 200 and 206 – 207 of Care Quality Commission handwritten acute hospital inspection notes for the Countess of Chester Hospital, regarding children and young people services including the neonatal unit, dated between 16/02/2016 and 19/02/2016
Source Date:
16 February 2016
Publication Date:
14 November 2024
INQ0017339 - Pages 206 - 209 of Handwritten Notes from the CQC Inspection, dated 17/02/2016.
Source Date:
17 February 2016
Publication Date:
12 September 2025
INQ0017339 – Page 206 and 213 of note for acute hospital inspection of the Countess of Chester Hospital, by the Care Quality Commission, dated 17/02/2016
Source Date:
17 February 2016
Publication Date:
17 October 2024
INQ0002287 – Pages 13-15 of Medical Records of [Child K]
Source Date:
17 February 2016
Publication Date:
9 September 2025
INQ0008927 – Pages 7 – 8 of Email correspondence between Sarah Harper-Lea and Alison Kelly titled “Inquest Investigation [Child A]” dated 23/02/2016 to 24/02/2015
Source Date:
23 February 2016
Publication Date:
28 November 2024
INQ0103135 – Page 1 of Draft summary of ‘table top review’ meeting held on 26/02/2016 at Alder Hey Hospital to discuss case of [Child I]
Source Date:
26 February 2016
Publication Date:
19 November 2024
INQ0042844 – Page 1 of document titled Neonatal synopsis in preparation for the business, dated March 2016
Publication Date:
17 October 2024
INQ0003089 – Pages 1 – 3 of Emails re ‘Thematic Review’ dated March 2016
Publication Date:
19 November 2024
INQ0003114 – Page 1 of email correspondence between [Stephen Brearey and] Countess of Chester staff relating to the thematic review, dated 02/03/2016
Publication Date:
16 October 2024
INQ0014226 – Page 1 of email correspondence between Stephen Brearey and colleagues, regarding the neonatal unit, dated 02/03/2016
Publication Date:
22 October 2024
INQ0010037 – Page 3 of Thematic Review of Neonatal Mortality 2015 – January 2016, from Countess of Chester Hospital, dated 02/03/2016
Publication Date:
4 November 2024
INQ0017339 – Inspection note by the Care Quality Commission, dated 04/03/2016
Publication Date:
10 October 2024
INQ0017339 – Page 262 of note from the the Care Quality Commission visit of the Countess of Chester Hospital, dated 04/03/2016
Publication Date:
21 October 2024
INQ0008927 – Page 5 of Email correspondence between Sarah Harper-Lea, Alison Kelly and others titled “Legal Services SUI Report” dated 04/03/2016
Publication Date:
28 November 2024
INQ0012847 – Pages 1 and 4 of Table from Royal College of Paediatrics and Child Health, titled Invited Reviews Programme – Countess of Chester – Summary of documents, dated 09/03/2016
Publication Date:
7 November 2024
INQ0005697 – email from Eirian Lloyd Powell to Stephen Breare, relating to annual mortality figures, dated 15/03/2016
Source Date:
15 March 2016
Publication Date:
21 October 2024
INQ0003089 – Page 2 of email correspondence between Eirian Lloyd Powell and Alison Kelly relating to the thematic review, dated between 17/03/2016 and 21/03/2016
Source Date:
17 March 2016
Publication Date:
16 October 2024
INQ0003558 – Page 2 of email correspondence between Eirian Powell and Alison Kelly regarding the thematic review, dated 17/03/2016
Source Date:
17 March 2016
Publication Date:
17 October 2024
INQ0003089 – Pages 1-2 of email correspondence between Alison Kelly, Eirian Powell and colleagues, relating to the thematic review, dated between 17/03/2016 and 14/04/2016
Source Date:
17 March 2016
Publication Date:
21 October 2024
INQ0003089 – Pages 1 – 2 of email correspondence between Eirian Lloyd Powell and Alison Kelly, relating to the thematic review, dated between 17/03/2016 and 14/04/2016
Source Date:
17 March 2016
Publication Date:
25 November 2024
INQ0003089 – Page 2 of Email correspondence between Alison Kelly, Eirian Powell and others titled “THEMATIC REVIEW” dated between 17/03/2016 and 21/03/2016
Source Date:
17 March 2016
Publication Date:
28 November 2024
INQ0003558 - Page 1 of Emails regarding the Thematic Review of the neonatal unit, dated 21/03/2016.
Source Date:
21 March 2016
Publication Date:
10 September 2025
INQ0042162 – Page 2 of Report from Ruth Millward titled Overview of Ongoing Patient Safety Incidents Reviews Reported to StEIS 2015/16 as Monitored by CCG, regarding incidents and their progress, dated 28/03/2016
Source Date:
28 March 2016
Publication Date:
4 November 2024
INQ0008894 – Report for HM Coroner, produced by Dr Rachel Lambie, regarding her involvement in the care of [Child A], dated 06/04/2016
Publication Date:
2 October 2024
INQ0001175 – Screenshot of Insulin/C-Peptide Results For [Child L] [dated 09/04/2016]
Publication Date:
9 October 2024
INQ0107095 – Pages 148 – 149 of handwritten notes by Alison Kelly, dated 11/04/2016
Source Date:
11 April 2016
Publication Date:
25 November 2024
INQ0101115 – Page 12 of Handwritten notes of Ian Harvey from 1:1 Meeting with Alison Kelly dated 11/04/2016
Source Date:
11 April 2016
Publication Date:
28 November 2024
INQ0005701 – email correspondence between Janet McMahon, Chris Green, Eirian Powell and Stephen Brearey, dated 13/04/2016
Source Date:
13 April 2016
Publication Date:
6 November 2024
INQ0001176 – Screenshot of call information relating to [Child L], dated 14/04/2016
Source Date:
14 April 2016
Publication Date:
9 October 2024
INQ0001169 – Page 12 – 13, 19, 21 and 22 of medical records of [Child L], dated between 09/04/2016 and 15/04/2016
Source Date:
15 April 2016
Publication Date:
7 October 2024
INQ0001169 - Page 12, 206 of medical records of Child-L.
Source Date:
15 April 2016
Publication Date:
12 September 2025
INQ0001169 – Pages 216 – 217 of Medical Records of [Child L]
Source Date:
15 April 2016
Publication Date:
9 October 2024
INQ0001283 – Page 13 of Medical Records of [Child M]
Source Date:
15 April 2016
Publication Date:
9 September 2025
INQ0003185 – Table of information prepared by Eirian Powell regarding [Child M] and two other incidents on the neonatal ward, dated 15/04/2016
Source Date:
15 April 2016
Publication Date:
16 October 2024
INQ0043309 – Pages 1, 3 – 4 and 102 of Papers for the Countess of Chester Hospital Safeguarding Strategy Board meeting, including agenda, meeting minutes and guidances, dated 15/04/2016
Source Date:
15 April 2016
Publication Date:
18 November 2024
INQ0006951 – Page 1 of Report by Eirian Powell titled “Additional Information – Monitoring regarding NNU mortalities between 18/02/2016 and 09/04/2016” dated 15/04/2016
Source Date:
15 April 2016
Publication Date:
28 November 2024
INQ0049390 - Pages 3 - 4 of Table prepared by Eirian Powell regarding [Child N], [Child O], [Child P] and [Child Q], dated 15/04/2016.
Source Date:
15 April 2016
Publication Date:
12 September 2025
INQ0003385 – Pages 1 to 5 of handwritten note by Alison Kelly, dated 18/04/2016
Source Date:
18 April 2016
Publication Date:
25 November 2024
INQ0003121 – Page 1 of Email correspondence between Alison Kelly and Ian Harvey titled “A few things to consider please?” dated 18/04/2016
Source Date:
18 April 2016
Publication Date:
28 November 2024
INQ0003393 – Page 2 of email correspondence between Alison Kelly, Stephen Brearey and Eirian Lloyd Powell, dated between 03/05/2016 and 04/05/2016
Publication Date:
21 October 2024
INQ0003087 – email correspondence between Ian Harvey and Alison Kelly, dated between 03/05/2016 and 04/05/2016
Publication Date:
25 November 2024
INQ0107818 – Pages 1 – 2 of Email correspondence between Alison Kelly, Ian Harvey and others titled “NNU Thematic Review” dated between 03/05/2016 and 06/05/2016
Publication Date:
25 November 2024
INQ0003087 – Email correspondence between Stephen Brearey, Alison Kelly and Eirian Powell, entitled ‘NNU Thematic Review’, dated 03/05/2016 and 04/05/2016
Publication Date:
29 November 2024
INQ0107818 – Email correspondence between Ian Harvey and Alison Kely, entitled ‘NNU Thematic Review’, dated between 03/05/2016 and 06/05/2016.
Publication Date:
29 November 2024
INQ0005724 – Pages 1-2 of Emails regarding the Neonatal Unit Thematic Review, dated between 03/05/2016 and 06/05/2016
Publication Date:
1 September 2025
INQ0003138 – Pages 1 of email correspondence between Alison Kelly and Karen Rees, relating to the thematic review, dated between 04/05/2016 and 05/05/2016
Publication Date:
21 October 2024
INQ0003138 – Page 1 – 2 of email correspondence between Stephen Brearey, Alison Kelly, Karen Rees and Sian Williams, relating to the thematic review and nurse associated with deaths, dated 04/05/2016
Publication Date:
25 November 2024
INQ0014241 – email correspondence relating to neonatal mortality review, dated 05/05/2016
Publication Date:
16 October 2024
INQ0003115 – email correspondence between Eirian Powell and Karen Rees relating to the NNU mortality document, dated 05/05/2016
Publication Date:
17 October 2024
INQ0003243 – [Page 1 of ] Report by Eirian Powell titled Neonatal Unit Review 2015-16, dated 05/05/2016.
Publication Date:
17 October 2024
INQ0003243 – Pages 1 – 2 of Document titled Neonatal Unit review 2015-16, dated 05/05/2016
Publication Date:
17 October 2024
INQ0003243 – Page 2 of Document titled Neonatal Unit review 2015 – 2016, relating to discussion between Dr Brearey, Anne Murphy and Eirian Powell, dated 05/05/2016
Publication Date:
21 October 2024
INQ0006890 – Pages 77 and 93 – 94 of document containing email correspondence from Eirian Lloyd Powell to Karen Rees dated 05/05/2016 and document tiled Neonatal Unit review 2015-2016
Publication Date:
21 October 2024
INQ0003115 – Page 1 of Email from Eirian Powell to Karen Rees and others, regarding neonatal review, dated 05/05/2016.
Publication Date:
19 November 2024
INQ0003243 – Page 1 of Report by Eirian Powell titled “Neonatal Unit Review 2015-16” dated 05/05/2016
Publication Date:
25 November 2024
INQ0003181 – Page 1 of Handwritten minutes of Alison Kelly from the NNU Thematic Review meeting dated 11/05/2016
Publication Date:
17 October 2024
INQ0003181 – Pages 1-2 of Handwritten Notes of Alison Kelly, dated 11/05/2016
Publication Date:
1 September 2025
INQ0015537 – Pages 2-3 of Handwritten Notes of Alison Kelly, dated between 11/05/2016 and 24/06/2016
Publication Date:
1 September 2025
INQ0005721 – Email from Stephen Brearey (Consultant Paediatrician, Countess of Chester Hospital) to Ravi Jayaram (Consultant Paediatrician, Countess of Chester Hospital) and colleagues, regarding reporting of any baby who suddenly or unexpectedly collapsed, dated 16/05/2016
Publication Date:
1 October 2024
INQ0005721 – Page 1 of email correspondence from Dr Stephen Brearey to Countess of Chester staff relating to rise in neonatal mortality, dated 16/05/2016
Publication Date:
17 October 2024
INQ0103144 – Page 1 of email correspondence from Stephen Brearey to Countess of Chester staff, [regarding rise in neonatal mortality] dated 16/05/2016
Publication Date:
13 November 2024
INQ0011608 – Exhibit SD/02 – Document containing training given by Stephanie Davies to new Coroner’s Officers, dated 20/05/2016
Publication Date:
20 January 2025
INQ0107710 – Pages 62 – 63 of Countess of Chester Hospital Annual Report and Accounts 2015/16, dated 24/05/2016
Publication Date:
22 January 2025
INQ0017295 – Pages 1 and 10 of Record of Care Quality Commission inspection titled NQAG Meeting Record Tool of Countess of Chester Trust (including Ellesmere Port Hospital), dated 26/05/2016
Publication Date:
14 November 2024
INQ0000569 – Pages 2 – 5, 7, 9, 11, 13 – 14, 19, 27 – 28, 33 – 34 of Facebook Messenger messages sent between Lucy Letby and Doctor U, dated between 14/06/2016 and 28/09/2016
Publication Date:
7 October 2024
INQ0000569 – Page 34 – Text message 1247, 1281- Facebook Messenger messages sent between Lucy Letby and Doctor U, dated between 14/06/2016 and 28/09/2016
Publication Date:
11 November 2024
INQ0000579 - Pages 16, 33 of Medical Records of [Child N].
Publication Date:
12 September 2025
INQ0000579 – Pages 40-45 of Medical Records of [Child N], dated 15/06/2016
Publication Date:
9 September 2025
INQ0003212 – Page 5 of minutes of a meeting of the Women & Children’s Care Governance Board, dated 16/06/2016
Publication Date:
8 October 2024
INQ0003212 – Pages 1 and 5 of Minutes of a meeting of the Women & Children’s Care Governance Board, dated 16/06/2016
Publication Date:
22 October 2024
INQ0103134 – Email from David Semple to [Stephen Brearey and ]Countess of Chester consultants, regarding risk management and issues, dated 16/06/2016
Publication Date:
4 November 2024
INQ0004308 – Page 5 of Minutes of the Women & Children’s Care Governance Board, regarding Neonatal Unit Thematic Review, dated 16/06/2016
Publication Date:
13 November 2024
INQ0003212 – Page 5 of Minutes of a meeting of the Women & Children’s Care Governance Board dated 16/06/2016
Publication Date:
28 November 2024
INQ0018008 – Pages 9 and 10 of Document titled Level 2 Root Cause Analysis Investigation Report, relating to [Child O], dated 23/06/2016
Publication Date:
22 October 2024
INQ0015537 – Page 3 of handwritten notes by Alison Kelly, dated between 23/06/2016 and 24/06/2016
Publication Date:
25 November 2024
INQ0102357 – Page 2 of handwritten note of meeting between Karen Townsend and Ravi Jayaram, dated 24/06/2016
Publication Date:
4 November 2024
INQ0003142 – Page 2 of email correspondence between Stephen Brearey and Alison Kelly, dated 26/06/2016
Publication Date:
13 November 2024
INQ0003142 – Pages 1 – 2 of Email correspondence between Alison Kelly, Stephen Brearey, Ian Harvey and others titled “NNU Mortality” dated 26/06/2016 to 27/06/201
Publication Date:
28 November 2024
INQ0001522 - Pages 18 - 25 of Medical Records of [Child Q].
Publication Date:
12 September 2025
INQ0002044 - Page 3 of medical records of [Child P].
Publication Date:
10 September 2025
INQ0002046 - Page 3 of medical records of Child Q (sic) [Child O].
Publication Date:
10 September 2025
INQ0005745 – email correspondence from Alison Kelly to Eirian Powell, Anne Murphy and Karen Rees, relating to concerns on the neonatal unit, dated 27/06/2016
Publication Date:
21 October 2024
INQ0009590 – Page 1 of Briefing from Royal College of Paediatrics and Child Health titled Briefing and data collection sheet – Service and design reviews, dated 27/06/2016.
Publication Date:
7 November 2024
INQ0106816 - Pages 5-7 of Handwritten Notes of Stephen Cross, dated 29/06/2016
Publication Date:
15 September 2025
INQ0005727 – Page 1 of Email correspondence between Ian Harvey and Alison Kelly titled “Steve B” dated 27/06/2016
Publication Date:
28 November 2024
INQ0005745 – Page 1 of Email correspondence between Alison Kelly, Eirian Powell and others titled “NNU concerns” dated 27/06/2016
Publication Date:
28 November 2024
INQ0003116 – Pages 1 and 2 of emails between Stephen Brearey (Consultant Paediatrician), Ravi Jayaram (Consultant Paediatrician), Karen Townsend and colleagues, regarding concerns held about the NNU and Lucy Letby staying on this unit, dated 28/06/2016
Publication Date:
1 October 2024
INQ0003116 – Page 2 of email regarding concerns of the senior paediatricians about the NNU, dated 28/06/2016
Publication Date:
3 October 2024
INQ0014306 – Page 1 and 2 of email correspondence between Eirian Powell and Countess of Chester staff relating to Letby’s welfare, dated 28/06/2016
Publication Date:
17 October 2024
INQ0005749 – Email chain between Stephen Brearey, Ravi Jayaram, Karen Townsend and colleagues, regarding concerns raised about Lucy Letby, dated between 28/06/2016 and 29/06/2016
Publication Date:
4 November 2024
INQ0009615 – Pages 2 and 4 – 5 of Email chain between Sue Eardley and Ian Harvey regarding arrangements for an invited review into neonatal services, dated between 28/06/2016 and 13/07/2016
Publication Date:
7 November 2024
INQ0005749 – Page 3 of Email from Dr Stephen Brearey to Karen Townsend and others, regarding NNU concerns, dated 28/06/2016
Publication Date:
13 November 2024
INQ0005744 – Pages 2 – 4 of Email correspondence between Dr Stephen Brearey, Karen Townsend and others titled “NNU Concerns” dated 28/06/2016
Publication Date:
28 November 2024
INQ0003116 – Email chain between Stephen Brearey, Ravi Jayaram and colleagues regarding concerns about the Neonatal Unit, dated 28/06/2016.
Publication Date:
15 January 2025
INQ0047571 – Page 1 of email correspondence relating to external investigations, dated between 29/06/2015 and 29/06/2016
Publication Date:
5 November 2024
INQ0047571 – Page 3 of Emails regarding potential referrals for external investigation, dated 29/06/2016
Publication Date:
29 August 2025
INQ0003112 – Email chain between John Gibbs, Ravi Jayaram, Stephen Brearey and others, regarding referring for external investigation, dated 29/06/2016
Publication Date:
1 October 2024
INQ0003112 – Pages 1 – 4 of an email chain discussing concerns of clinicians and attempts to meet with senior executives, dated 29/06/2016
Publication Date:
3 October 2024
INQ0003371 – Pages 1 – 3 of Handwritten note [by Stephen Cross] of meeting between executives and consultants, [regarding initial investigations into NNU mortality rate, recurring themes and potential actions], dated 27/06/2016 [correction: 29/6/2016]
Publication Date:
27 November 2024
INQ0003364 - Handwritten Notes [by Stephen Cross], dated 29/06/2016
Publication Date:
15 September 2025
INQ0008624 – Pages 1 – 2 of Datix form relating to [Child P], dated 29/06/2016
Publication Date:
17 October 2024
INQ0003371 – Pages 1 – 3 of handwritten notes of a meeting between paediatricians and executives, dated 29/06/2016
Publication Date:
5 November 2024
INQ0003371 – Page 1 of handwritten note of meeting between paediatricians and executives, dated 29/06/2016
Publication Date:
13 November 2024
INQ0003112 – Pages 2 – 3 of email correspondence between Ian Harvey, Ravi Jayaram and other Countess of Chester staff, dated 29/06/2016
Publication Date:
13 November 2024
INQ0003371 – Pages 1, 2 and 3 of meeting minutes between paediatricians and executives, regarding NNU mortality rate, dated 29/06/2016
Publication Date:
19 November 2024
INQ0103148 – Email from Dr Stephen Brearey to Ruth Millward, regarding thematic review and mortality reviews, dated 29/06/2016
Publication Date:
19 November 2024
INQ0003371 – Page 3 of Minutes of the meeting between Paediatricians and executives, dated 29/06/2016
Publication Date:
25 November 2024
INQ0015537 - Pages 5-6 of Handwritten Notes of Alison Kelly, dated 29/06/2016
Publication Date:
15 September 2025
INQ0047571 – Page 1 of Email correspondence between Alison Kelly and Ian Harvey titled “Should we refer ourselves to external investigation?” dated 29/06/2016
Publication Date:
25 November 2024
INQ0003112 – Pages 1 – 2 of Email correspondence between Dr Ravi Jayaram, Dr Stephen Brearey and others titled “Should we refer ourselves to external investigation?” dated 29/06/2016
Publication Date:
28 November 2024
INQ0003360 – Handwritten notes of a meeting between Stephen cross and Ian Harvey, prepared by Stephen Cross, dated 29/06/2016
Publication Date:
28 November 2024
INQ0003371 – Pages 1 -2 of Handwritten notes of Stephen Cross from a meeting between Paediatricians and executives dated 29/06/2016
Publication Date:
28 November 2024
INQ0015679 – Page 1 of handwritten note of meeting dated 29/06/2016
Publication Date:
28 November 2024
INQ0047571 – Pages 1 – 2 of Email correspondence between Dr Murthy Saladi, paediatric consultants, Alison Kelly and Ian Harvey titled “Should we refer ourselves to external investigation?” dated 29/06/2016
Publication Date:
28 November 2024
INQ0014249 – Page 1 of Emails regarding NNU Concerns, dated 29/06/2016
Publication Date:
29 August 2025
INQ0102065 – Page 2 of email chain between Ravi Jayaram (Consultant Paediatrician, Countess of Chester Hospital), John Gibbs (Consultant Paediatrician, Countess of Countess of Chester Hospital) and other colleagues, discussing an article on neonatal air embolism, dated 30/06/2016
Publication Date:
1 October 2024
INQ0003362 – Pages 1, 2, 4 and 5 of minutes of meeting between paediatricians and executives regarding actions taken, dated 30/06/2016.
Publication Date:
3 October 2024
INQ0003362 – Pages 1 and 4 – 5 of minutes of meeting, chaired by Tony Chambers, regarding the increased mortality rate and concerns on the neonatal unit, dated 30/06/2016
Publication Date:
8 October 2024
INQ0018046 – Page 1 of Occupational Health Management Referral for Letby, dated 30/06/2016
Publication Date:
9 October 2024
INQ0003273 – Page 2 of Document titled NNU Action Planning Meeting, dated 30/06/2016
Publication Date:
21 October 2024
INQ0014125 – Document titled NNU Action Planning Meeting, dated 30/06/2016
Publication Date:
4 November 2024
INQ0005151 – Pages 1 – 2 of Notes of the Countess of Chester Hospital Neonatal Unit (NNU) Action Planning Meeting, dated 30/06/2016
Publication Date:
5 November 2024
INQ0005196 – Pages 1 – 2 of Notes of the Countess of Chester Hospital Neonatal Unit (NNU) Action Planning Meeting, dated 30/06/2016
Publication Date:
5 November 2024
INQ0009595 – Pages 2 – 6 of Review Proposal from Royal College of Paediatrics and Child Health titled Review of Neonatal service in Countess of Chester Hospital NHS Foundation Trust, dated 30/06/2016
Publication Date:
7 November 2024
INQ0003362 – Pages 1 – 6 of Minutes of meeting regarding Letby’s investigation, dated 30/06/2016
Publication Date:
13 November 2024
INQ0017411 – Page 1 of Email from Alison Kelly to Ann Ford entitled “Neonatal Unit – Update” dated 30/06/2016
Publication Date:
14 November 2024
INQ0003362 – Pages 1 and 6 of Minutes of meeting, chaired by Tony Chambers, regarding Lucy Letby investigation, dated 30/06/2016
Publication Date:
19 November 2024
INQ0003362 – Pages 4 – 5 of handwritten note of meeting between executives and consultants, dated 30/06/2016
Publication Date:
25 November 2024
INQ0017411 – Page 1 of email correspondence between Alison Kelly and Ann Ford, relating to an update to the CQC about the neonatal unit, dated 30/06/2016
Publication Date:
25 November 2024
INQ0003361 – Pages 1 – 2 of handwritten notes by Stephen Cross of a meeting dated 30/06/2016 [Ian Harvey]
Publication Date:
26 November 2024
INQ0015639 – Pages 51 and 53 of handwritten note by Sue Hodkinson, dated 30/06/2016
Publication Date:
26 November 2024
INQ0015639 – Pages 54 – 61 of Sue Hodkinson’s handwritten notes, dated 30/06/2016
Publication Date:
26 November 2024
INQ0015639 – Pages 54 – 55, 58 – 59, 60 and 62 of handwritten note by Sue Hodkinson, dated 30/06/2016
Publication Date:
26 November 2024
INQ0003361 – Page 2 of Handwritten notes of Stephen Cross from a meeting between ‘DN, TC, IH, AK, Sue, SPC’ dated 30/06/2016
Publication Date:
28 November 2024
INQ0003362 – Pages 1 – 5 of handwritten note by Stephen Cross of meeting, dated 30/06/2016
Publication Date:
28 November 2024
INQ0015639 – Pages 55 and 58 of Handwritten notes of Susan Hodkinson from ‘Consultant meeting’ dated 30/06/2016
Publication Date:
28 November 2024
INQ0015639 – Page 58 of Sue Hodkinson’s handwritten notebook, dated 30/06/2016
Publication Date:
29 November 2024
INQ0006023 – Pages 1 – 4 of handwritten notes by Stephen Cross, dated 30/06/2016
Publication Date:
2 December 2024
INQ0006023 – Pages 1, 4 and 6 of handwritten notes by Stephen Cross of a meeting dated 30/06/2016
Publication Date:
2 December 2024
INQ0017411 – email correspondenxe between Alison Kelly and Ann Ford, regarding the neonatal unit’s request for an independent review into neonatal deaths, dated 30/06/2016
Publication Date:
14 January 2025
INQ0014630 – Pages 1 – 2 of Email from Peter Groggins (NHS England) to Marie Sedgwick (NHS England) and colleagues regarding [Child O]’s Serious Incident report, dated 30/06/2016
Publication Date:
17 January 2025
INQ0003361 – Meeting minutes of Executive team, dated 30/06/2016
Publication Date:
29 January 2025
INQ0003492 – Page 11 of Draft report by the Countess of Chester Hospital NHS Foundation Trust titled Position Paper – Neonatal Unit Mortality 2013-2016, dated July 2016
Publication Date:
1 October 2024
INQ0003492 – Pages 1 – 3 of Draft report by the Countess of Chester Hospital NHS Foundation Trust titled Position Paper – Neonatal Unit Mortality 2013-2016, dated July 2016
Publication Date:
3 October 2024
INQ0004314 – Pages 1 – 3 of Handwritten minutes of the Executives Neonatal meeting with Dr Stephen Brearey, dated 04/07/2016
Publication Date:
5 November 2024
INQ0002445 – email correspondence between Tony Newman and Alison Kelly, entitled ‘Telephone call’, dated between 04/07/2016 and 12/07/2016
Publication Date:
8 January 2025
INQ0004314 – Meeting minutes, dated 04/07/2016
Publication Date:
29 January 2025
INQ0002693 – Email correspondence regarding communications about neonatal services dated between 05/07/2016 and 07/07/2016
Publication Date:
1 October 2024
INQ0002693 – Page 7 of email correspondence regarding communications about neonatal services dated between 05/07/2016 and 07/07/2016
Publication Date:
3 October 2024
INQ0005121 – Page 3 of Report from the Countess of Chester Hospital titled Mortality Review, regarding [Child O], dated 05/07/2016
Publication Date:
7 October 2024
INQ0004884 – Page 1 and 3 of Document titled Mortality Review relating to [Child P], dated 05/07/2016
Publication Date:
17 October 2024
INQ0005121 – Pages 1 and 3 of Report from the Countess of Chester Hospital titled Mortality Review, dated 05/07/2016
Publication Date:
5 November 2024
INQ0101934 – Attendance note of meeting between DAC Beachcroft and Countess of Chester Hospital, dated 05/07/2016
Publication Date:
5 November 2024
INQ0004884 – Page 1 of Report from the Countess of Chester Hospital titled Mortality Review, regarding [Child P], dated 05/07/2016
Publication Date:
6 November 2024
INQ0002694 – Page 9 of email correspondence between Ravi Jayaram and Stephen Brearey, dated 05/07/2016
Publication Date:
13 November 2024
INQ0101934 – Page 1 of Ian Pace’s attendance note of a call from Dee Appleton-Cairns on 5 July 2016
Publication Date:
21 November 2024
INQ0102040 – Page 2 of handwritten note of private NED meeting, dated 05/07/2016
Publication Date:
2 December 2024
INQ0102040 – Page 2 of Ros Fallon’s handwritten notes
Publication Date:
3 December 2024
INQ0012667- Email chain between Lesley Patel and Paula Wedd regarding Neonatal Unit issues at the Countess of Chester Hospital, dated 05/07/2016.
Publication Date:
16 January 2025
INQ0102984 – Email from Lesley Patel to colleagues at NHS England, regarding Neonatal Services Serious Issues, dated 05/07/2016.
Publication Date:
16 January 2025
INQ0004891 – Email regarding inquest statement relating to [Child O] and [Child P], dated 06/07/2016
Publication Date:
2 October 2024
INQ0001445 – Email correspondence regarding [Child P], dated 06/07/2016
Publication Date:
7 October 2024
INQ0014261 – Page 3 of email correspondence between Alison Kelly and Tony Newman, following a telephone call, dated 06/07/2016
Publication Date:
25 November 2024
INQ0004888 – Page 1 of email titled ‘NNU Security Review’ dated 06/07/2016
Publication Date:
26 November 2024
INQ0015639 – Page 72 of handwritten note by Sue Hodkinson, dated 06/07/2016
Publication Date:
26 November 2024
INQ0101091 – Page 396 of Simon Holden’s handwritten meeting notes dated 06/07/2016
Publication Date:
3 December 2024
INQ0002965 – Page 4 of email correspondence between Tony Newman and Alison Kelly, titled “Telephone call”, dated 06/07/2016
Publication Date:
13 December 2024
INQ0107706 – Pages 129-130 – Handwritten notes of Stephen Cross, regarding the Incident Room, dated 06/07/2016
Publication Date:
17 January 2025
INQ0002682 – Meeting minutes of Executive Team, dated 06/07/2016
Publication Date:
29 January 2025
INQ0014414 – External communication from the Countess of Chester Hospital regarding the change in admission arrangements for neonatal services, dated 07/07/2016
Publication Date:
3 October 2024
INQ0004914 – Information from the Countess of Chester Hospital NHS Foundation Trust regarding changes of admission arrangements on the neonatal unit, dated 07/07/2016
Publication Date:
14 October 2024
INQ0004319 – Pages 1, 3 and 5 of meeting minutes between Countess of Chester colleagues, dated 07/07/2016
Publication Date:
5 November 2024
INQ0103147 - Press Release / External Statement from the Countess of Chester Hospital, dated 07/07/2016.
Publication Date:
12 September 2025
INQ0004320 – Page 1 of handwritten note by Alison Kelly, dated 07/07/2016
Publication Date:
25 November 2024
INQ0002682 – Page 3 of Minutes of the Executive Team Meeting dated 07/07/2016
Publication Date:
28 November 2024
INQ0101115 – Page 21 of Handwritten notes of Ian Harvey titled ‘NNU’ dated 07/07/2016
Publication Date:
28 November 2024
INQ0014636 – Pages 1 and 3 of Email from Peter Groggins (NHS England) to Lisa Cooper (Alder Hey Children’s Hospital) and colleagues, dated 07/07/2016
Publication Date:
17 January 2025
INQ0107706 – Pages 131-132 – Handwritten notes of Stephen Cross of an Executive Team meeting, dated 7 July 2016.
Publication Date:
17 January 2025
INQ0002837 – Powerpoint presentation titled Analysis of NNU Mortality Rates
Publication Date:
2 September 2025
INQ0003174 – Pages 1 – 2 of [Boardroom briefing notes dated 08/07/2016]
Publication Date:
6 November 2024
INQ0002822 – Page 1 of email correspondnece from Tony Chambers to all COCH staff, titled “IMPORTANT MESSAGE REGARDING NEONATAL SERVICES” dated 08/07/2016
Publication Date:
26 November 2024
INQ0003607 – Page 2 of email correspondence between Alison Kelly and Tony Newman, titled “Telphone call”, dated 08/07/2016
Publication Date:
26 November 2024
INQ0003174 – Pages 1 – 3 of List of attendees and actions from 09:00 Opening / Morning Briefing Meeting and 12:30 Briefing dated 08/07/2016
Publication Date:
28 November 2024
INQ0003174 – Pages 1 and 3 of List of attendees at Silver Command, dated 08/07/2016
Publication Date:
2 December 2024
INQ0012086 – Page 950 – Emails between various regarding messages of support to the Countess of Chester Hospital Neonatal Unit from Liverpool Women’s Hospital, dated between 08/07/2016 and 11/07/2016
Publication Date:
16 January 2025
INQ0004657 – Table titled Urgent Care Risk Register High Risks, dated between 01/06/2010 and 11/07/2016
Publication Date:
2 September 2025
INQ0003336 - Page 8 of Neonatal Services Action Log, dated 11/07/2016.
Publication Date:
12 September 2025
INQ0009599 – Page 1 of email correspondence between Sue Eardley and Ian Harvey, regarding arrangements for an invited review into neonatal services, dated 12/07/2016
Publication Date:
7 November 2024
INQ0009599 – Pages 1-2 of Emails regarding RCPCH review preparation, dated between 30/06/2016 and 12/07/2016
Publication Date:
2 September 2025
INQ0009599 – Pages 2-4 of Emails regarding RCPCH review preparation, dated between 28/06/2016 and 12/07/2016
Publication Date:
29 August 2025
INQ0101942 – Page 1 of Email chain between Corinne Slingo, Ian Pace, Sue Hodkinson and colleagues, regarding confidential advice in respect of the Neonatal Unit, dated between 12/07/2016 and 18/07/2016
Publication Date:
21 November 2024
INQ0107706 – Page 133 – Handwritten notes of Stephen Cross, regarding a meeting on 12/07/2016
Publication Date:
17 January 2025
INQ0003365 – Page 4 of minutes of the meeting between consultants and executives, regarding steps taken in relation to Letby, dated 13/07/2016
Publication Date:
3 October 2024
INQ0004234 – Pages 4 – 7 of Handwritten notes of meeting on 13 July 2016
Publication Date:
5 November 2024
INQ0003365 – Pages 4 – 5 of Minutes from the Neonates meeting, dated 13/07/2016
Publication Date:
13 November 2024
INQ0003365 – Page 9 of Minutes from the Neonates meeting, regarding NNU mortality rate and response, dated 13/07/2016
Publication Date:
19 November 2024
INQ0003365 – Meeting minutes, dated 13/07/2016
Publication Date:
29 January 2025
INQ0006769 – Emails between Dr Stephen Brearey, Ian Harvey, Ruth Millward and others at Countess of Chester Hospital NHS Trust, regarding the Royal College of Paediatrics and Child Health review, dated between 14/07/2016 and 15/07/2016
Publication Date:
22 October 2024
INQ0002731 – Page 1 of email correspondence between Eirian Powell, Sian Williams and Yvonne Griffiths, dated between 14/07/2016 and 15/07/2016
Publication Date:
5 November 2024
INQ0003147 – Page 1 of Letter from Sian Williams to Lucy Letby, dated 14/07/2016
Publication Date:
5 November 2024
INQ0004327 – Handwritten note of a meeting, dated 14/07/2016
Publication Date:
5 November 2024
INQ0005769 – Pages 2 and 4 of email correspondence between Sian Williams and Sue Hodkinson, dated 14/07/2016
Publication Date:
5 November 2024
INQ0003147 – Pages 1 – 2 of Letter from Sian Williams to Letby, dated 14/07/2016
Publication Date:
6 November 2024
INQ0004216 – Page 1 of Minutes of the Extra-Ordinary Board of Directors Meeting, regarding mortality rates on NNU, dated 14/07/2016
Publication Date:
19 November 2024
INQ0006769 – Pages 1 and of Emails between Dr Stephen Brearey and Ian Harvey and others, regarding the RCPCH review, dated between 14/07/2016 and 15/07/2016
Publication Date:
19 November 2024
INQ0002839 – Letter from Sian Williams to Letby, dated 14/07/2016
Publication Date:
26 November 2024
INQ0003238 – Pages 1 and 4 – 9 of minutes of meeting of Extra-Ordinary Board of Directors, dated 14/07/2016
Publication Date:
2 December 2024
INQ0003238 – Pages 1, 4,6 and 8 – 9 of Minutes of a meeting between Extra-Ordinary Board of Directors, dated 14/07/2016
Publication Date:
3 December 2024
INQ0107706 – Pages 134-137 – Handwritten notes of Stephen Cross of a meeting on 14/07/2016
Publication Date:
17 January 2025
INQ0004216 – Meeting minutes of Extra-Ordinary Board of Directors, dated 14/07/2016
Publication Date:
29 January 2025
INQ0002879 – email correspondence from Eirian Powell to all Countess of Chester Hospital neonatal unit nurses, regarding staff undertaking further clinical supervision, dated 15/07/2016 and 09/08/2016
Publication Date:
10 October 2024
INQ0002879 – email correspondence from Eirian Powell to all Countess of Chester Hospital neonatal unit nurses, regarding staff undertaking further clinical supervision, dated 15/07/2016 and 09/08/2016
Publication Date:
14 October 2024
INQ0002879 – Page 91 – email correspondence from Yvonne Griffiths to all NNU nurses, titled “CLINICAL SUPERVISION”, dated 15/07/2016
Publication Date:
26 November 2024
INQ0002960 – Pages 1 – 3 of email correspondence between Tony Millea, Clare Edwards and Sue Hodkinson dated between 15/07/2016 and 17/07/2016
Publication Date:
26 November 2024
INQ0002458 – Letter from Karen Rees to Letby, relating to Letby’s redeployment, dated 18/07/2016
Publication Date:
21 October 2024
INQ0101941 – handwritten note by Corinne Slingo relating to the Countess of Chester Hospital, dated 18/07/2016
Publication Date:
21 November 2024
INQ0101942 – email correspondence from Corinne Slingo to Sue Hodkinson, Debra Cleverley and Ian Pace, dated 18/07/2016
Publication Date:
21 November 2024
INQ0102205 – Page 1 of Ian Pace’s attendance note of a call from Sue Hodkinson on 18 July 2016
Publication Date:
21 November 2024
INQ0004597 – Pages 1 – 2 of email correspondence between Sue Hodkinson, Corinne Slingo and Ian Pace, titled “Legally privileged – confidential advice re neonatal unit”, dated 18/07/2016
Publication Date:
26 November 2024
INQ0003397 – Pages 2-3 of Emails regarding legal advice surrounding the neonatal unit, dated 18/07/2016
Publication Date:
2 September 2025
INQ0107706 – Pages 138-139 – Handwritten notes of Stephen Cross of a meeting on 18/07/2016
Publication Date:
17 January 2025
INQ0003368 – Meeting minutes of Executive Team, dated 18/07/2016
Publication Date:
29 January 2025
INQ0007197 – Notes of an Executive Team meeting, dated 20/07/2016
Publication Date:
5 November 2024
INQ0004330 – Page 1 of handwritten meeting notes, dated 20/07/2016.
Publication Date:
27 November 2024
INQ0006890 – Page 112 – Email from Ian Harvey to Stephen Brearey, Chris Green, Sue Hodkinson and Alison Kelly, dated 20/07/2016
Publication Date:
29 January 2025
INQ0003213 – Pages 3 – 4 of Minutes of a meeting between the Women & Children’s Care Governance Board, dated 21/07/2016
Publication Date:
16 October 2024
INQ0003213 – Pages 1 and 4 – 5 of Minutes of a meeting between the Women & Children’s Care Governance Board, including discussion of risks including increased mortality within the neonatal unit, dated 21/07/2016
Publication Date:
4 November 2024
INQ0003213 – Page 1 and 3 of Minutes of a meeting between the Women & Children’s Care Governance Board, dated 21/07/2016
Publication Date:
13 November 2024
INQ0107682 – Exhibit NY01, Minutes of an NNU meeting, dated 26/07/2016.
Publication Date:
17 February 2025
INQ0049845 – Pages 1 – 2, 4, 8 and 10 of Countess of Chester Hospital’s Executive Risk Register for July 2016, referencing an apparent increase in mortality on the Neonatal Unit in 2015 and 2016, dated 27/07/2016
Publication Date:
4 November 2024
INQ0049845 – Page 2 of Executive Risk register – July 2016
Publication Date:
27 November 2024
INQ0107706 – Pages 145-146 – Handwritten notes of Stephen Cross of an Executive Team meeting on 27/07/2016.
Publication Date:
29 January 2025
INQ0017433 – Pages 1 and 106 – 108 of Care Quality Commission’s Quality Report for The Countess of Chester Hospital, regarding the quality of care at the hospital on inspection visit date February 2016
Publication Date:
14 November 2024
INQ0017433 - Page 110 of the CQC's 2016 Quality Inspection Report, dated 29/07/2016.
Publication Date:
12 September 2025
INQ0014760 – Pages 1, 2 and 6 of Paper from NHS England, Surveillance Report to Regional Quality Surveillance Group (RQSG) Meeting titled NHS England North (Cheshire & Merseyside) Exception Report between 01/06/2016 and 31/07/2016 regarding key areas for review and consideration for action / updates by the RQSG, dated 31/07/2016
Publication Date:
17 January 2025
INQ0010214 – Pages 1, 4 – 5, 7, 9 and 12 – 13 of RCPCH Invited Reviews Programme, Invited reviews – a guide, dated August 2016
Source Date:
1 August 2016
Publication Date:
7 November 2024
INQ0010214 – Pages 1, 6 and 8 – 9 of Guidance from the Royal College of Paediatrics and Child Health titled Invited reviews – A guide, dated August 2016
Source Date:
1 August 2016
Publication Date:
11 November 2024
INQ001214 – Pages 1 and 7 of Guidance from the Royal College of Paediatrics and Child Health titled Invited reviews – A guide, dated August 2016
Source Date:
1 August 2016
Publication Date:
11 November 2024
INQ0010214 – Pages 1, 4, 6 – 7, 8 – 9 and 13 of Guidance from the Royal College of Paediatrics and Child Health titled Invited reviews – A guide, dated August 2016
Source Date:
1 August 2016
Publication Date:
12 December 2024
INQ0009591 page 1 – Terms of Reference from Royal College of Paediatrics and Child Health titled Review of Neonatal Unit at the Countess of Chester Hospital NHS FT, under the Invited Review Mechanism of the Royal College of Paediatrics and Child Health, dated August 2016.
Source Date:
1 August 2016
Publication Date:
12 December 2024
INQ0050940 – Executive Risk Register dated August 2016
Source Date:
1 August 2016
Publication Date:
29 January 2025
INQ0009597 – Page 2 of a letter from Sue Eardley to Ian Harvey, dated 02/08/2016
Source Date:
2 August 2016
Publication Date:
29 November 2024
INQ0007197 – Pages 138 and 139 Handwritten notes of Stephen Cross from meeting with various executive team members dated 03/08/2016
Source Date:
3 August 2016
Publication Date:
26 November 2024
INQ0050165 – Page 2 – Extract from board pack for Executive team meeting, dated 03/08/2016.
Source Date:
3 August 2016
Publication Date:
29 January 2025
INQ0008587 – Page 1 and Page 7 of Document titled SUI Panel 04 August 2016 [dated 04/08/2016], Legal Services Report for the Period 1 July 2016 – 1 August 2016
Source Date:
4 August 2016
Publication Date:
4 November 2024
INQ0002042 – Page 174 – email correspondence between Pryers Solicitors and the Coroners Office, titled “Inquest into death of [Child A] (DOB [PD].06.2015), dated 04/08/2016
Source Date:
4 August 2016
Publication Date:
6 December 2024
INQ0002879 – Email from Eirian Powell to all Countess of Chester Neonatal Staff relaing to secondment opportunities in the Trust, dated 09/08/2016
Source Date:
9 August 2016
Publication Date:
17 October 2024
INQ0002042 – Page 167 – Letter from HM Senior Coroner to Stephen Cross, dated 11/08/2016
Source Date:
11 August 2016
Publication Date:
6 December 2024
INQ0002042 – Page 169 – Letter from HM Senior Coroner to Pryers Solicitors, dated 11/08/2016
Source Date:
11 August 2016
Publication Date:
6 December 2024
INQ0002042 – Page 173 – email correspondence between Pryers Solicitors and Nicholas Rheinberg, titled “[Child A] deceased”, dated 11/08/2016
Source Date:
11 August 2016
Publication Date:
6 December 2024
INQ0012846 – email from Sue Eardley to Alex Mancini, David Milligan, Graham Stewart and Claire McLaughlan, dated 12/08/2016
Source Date:
12 August 2016
Publication Date:
7 November 2024
INQ0002042 – Page 186 – email correspondence from Stephen Cross to Nicholas Rheinberg, titled “For the attention of Mr Rheinberg”, dated 12/08/2016
Source Date:
12 August 2016
Publication Date:
6 December 2024
INQ0014679 – Emails between various, regarding update from the Neonatal Unit at the Countess of Chester Hospital, dated between 12/08/2016 and 16/05/2017
Source Date:
12 August 2016
Publication Date:
16 January 2025
INQ0106997 – Emails between various following an update call between the Countess of Chester Hospital and Specialised Commissioning, dated between 12/08/2016 and 16/05/2017
Source Date:
12 August 2016
Publication Date:
16 January 2025
INQ0004335 – page 6 of Minutes of the Patient Experience Committee meeting, dated 15/08/2016
Source Date:
15 August 2016
Publication Date:
13 February 2025
INQ0050707 – email from Joshua Swash for the attention of Nicholas Rheinberg, titled “NHS Confidential – URGENT Inqust”, dated 19/08/2016
Source Date:
19 August 2016
Publication Date:
6 December 2024
INQ0017296 – Page 1 of agenda for engagement meeting between Care Quality Commission and Countess of Chester Hospital, dated 24/08/2016
Source Date:
24 August 2016
Publication Date:
5 November 2024
INQ0002964 – Page 1 of email correspondence between Alison Kelly and Tony Newman, regarding review of the neonatal ward, dated 31/08/2016
Source Date:
31 August 2016
Publication Date:
25 November 2024
INQ0014604 – Page 24 of Notes from Royal College of Paediatric and Child Health interview of Kathryn de Beger, dated 01/09/2016
Source Date:
1 September 2016
Publication Date:
9 October 2024
INQ0004625 – Page 1 of Document titled Urgent Care Risk Register, detailing high risk issues in the urgent care division of the Countess of Chester Hospital, dated September 2016
Source Date:
1 September 2016
Publication Date:
17 October 2024
INQ0014602 – Pages 1 – 3 of Notes by Claire McLaughlin from meeting between Claire McLaughlan, Lucy Letby and Hayley Cooper, dated 01/09/2016
Source Date:
1 September 2016
Publication Date:
6 November 2024
INQ0010124 – Pages 1, 6 and 8 – 9 of Handwritten note by Sue Eardley regarding interviews with Countess of Chester staff, dated 01/09/2016
Source Date:
1 September 2016
Publication Date:
7 November 2024
INQ0010124 – Pages 1 – 4 and 23 of handwritten notes of Royal College of Paediatrics and Child Health interview with Ian Harvey and Alison Kelly, dated 01/09/2016
Source Date:
1 September 2016
Publication Date:
11 November 2024
INQ0010131 – Pages 1 and 6 – Draft version of Royal College of Paediatrics and Child Health’s Service Review dated September 2016
Source Date:
1 September 2016
Publication Date:
11 November 2024
INQ0010145 – Pages 1, 7 and 18 – 19 of Draft Royal College of Paediatrics and Child Health Invited Reviews Programme’s Service Review, dated 01/09/2016
Source Date:
1 September 2016
Publication Date:
11 November 2024
INQ0010147 – Page 7 of Draft version of Royal College of Paediatrics and Child Health’s Service Review dated September 2016
Source Date:
1 September 2016
Publication Date:
11 November 2024
INQ0014602 – Pages 1 and 3 of Notes from meeting between Claire McLaughlan, Lucy Letby and Hayley Cooper, dated 01/09/2016
Source Date:
1 September 2016
Publication Date:
11 November 2024
INQ0014604 – Pages 1 – 7, 9 – 10, 25 and 28 of transcribed notes of Royal College of Paediatrics and Child Health interview with Ian Harvey and Alison Kelly, dated 01/09/2016
Source Date:
1 September 2016
Publication Date:
11 November 2024
INQ0014604 – Page 25 of Notes of John Gibbs’ interview with Royal College of Paediatric and Child Health, dated 01/09/2016
Source Date:
1 September 2016
Publication Date:
18 November 2024
INQ0014604 – Page 1 of notes of John Gibbs’ interview with the Royal College of Paediatrics and Child Health, dated 01/09/2016
Source Date:
1 September 2016
Publication Date:
29 November 2024
INQ0014639 – Pages 1 – 4 of Report for North West Neonatal Operational Delivery Network titled Neonatal Mortality at Countess of Chester Hospital, dated 01/09/2016
Source Date:
1 September 2016
Publication Date:
17 January 2025
INQ0010121 – Meeting minutes from Claire McLaughlan, Lucy Letby and Hayley Cooper, dated 01/09/2016.
Source Date:
1 September 2016
Publication Date:
29 January 2025
INQ0014605 – Page 31 of notes taken by the Royal College of Paediatric and Child Health, interviewing Dr McCormack, dated 02/09/2016
Source Date:
2 September 2016
Publication Date:
8 October 2024
INQ0002746 – Pages 3 – 4 of email correspondence between Alison Kelly, Tony Millea and Karen Rees, dated 02/09/2016
Source Date:
2 September 2016
Publication Date:
21 October 2024
INQ0002746 – email correspondence relating to Letby’s grievance, dated 02/09/2016
Source Date:
2 September 2016
Publication Date:
6 November 2024
INQ0014605 – Page 6 of Notes taken by Sue Eardley relating to interviews with Countess of Chester staff, dated 02/09/2016
Source Date:
2 September 2016
Publication Date:
7 November 2024
INQ0014605 – Pages 6, 22 and 34 of notes taken by Sue Eardley regarding interviews with Countess of Chester staff, dated 02/09/2016
Source Date:
2 September 2016
Publication Date:
11 November 2024
INQ0012781 – Page 1 of email correspondence between Anne McKenzie, Sharon Dodd and Sue Eardley regarding the Cheshire CDOP Annual report, dated between 02/09/2016 and 18/10/2016
Source Date:
2 September 2016
Publication Date:
18 November 2024
INQ0014605 – Pages 19 – 21 of notes taken by Sue Eardley, dated 02/09/2016
Source Date:
2 September 2016
Publication Date:
18 November 2024
INQ0014605 – Pages 33 – 35 of Case note review by Sue Eardley, dated 02/09/2016
Source Date:
2 September 2016
Publication Date:
27 November 2024
INQ0014605 – Pages 1 and 6 of notes prepared by Sue Eardley the review of the Countess of Chester, dated 02/09/2016
Source Date:
2 September 2016
Publication Date:
29 November 2024
INQ0012781- Email chain between Anne McKenzie, Sharon Dodd and Sue Eardley, regarding the Cheshire CDOP Annual Review, dated between 02/09/2016 and 18/10/2016.
Source Date:
2 September 2016
Publication Date:
14 January 2025
INQ0002459- Letter from Karen Rees to Lucy Letby, dated 02/09/2016.
Source Date:
2 September 2016
Publication Date:
29 January 2025
INQ0009611 – Pages 1 – 2 of Letter from Sue Eardley, Royal College of Paediatrics and Child Health, to Ian Harvey, Countess of Chester Hospital, regarding the invited review of neonatal service, dated 05/09/2016
Source Date:
5 September 2016
Publication Date:
7 November 2024
INQ0003120 – Pages 1 – 3 of Letter from the Royal College of Paediatric and Child Health to Ian Harvey, dated 05/09/2016
Source Date:
5 September 2016
Publication Date:
12 November 2024
INQ0003120 – Pages 1-2 of a letter from the Royal College of Paediatrics and Child Health [Sue Eardley] to Ian Harvey, concerning ‘Invited Review of the Neonatal service and COCH’, dated 05/09/2016
Source Date:
5 September 2016
Publication Date:
25 November 2024
INQ0009611 – Page 2 of Letter from Sue Eardley to Ian Harvey, dated 05/09/2016
Source Date:
5 September 2016
Publication Date:
12 December 2024
INQ0003120 – Letter from Sue Eardley to Ian Harvey, dated 05/09/2016.
Source Date:
5 September 2016
Publication Date:
29 January 2025
INQ0008964 – Page 95 – Grievance Registration dated 07/09/2016
Source Date:
7 September 2016
Publication Date:
26 November 2024
INQ0003369 – Meeting minutes of Executive Team, dated 07/09/2016
Source Date:
7 September 2016
Publication Date:
29 January 2025
INQ0051885 – Action notes for the Executive Directors Group, dated 07/09/2016.
Source Date:
7 September 2016
Publication Date:
29 January 2025
INQ0002748 – email correspondence between Hayley Griffiths (nee Cooper), Tony Chambers and Sir Duncan Nichol, relating to Letby’s grievance, dated 08/09/2016
Source Date:
8 September 2016
Publication Date:
6 November 2024
INQ0003123 – Page 2 of Emails between Ian and Dr Hawdon, dated 08/09/2016
Source Date:
8 September 2016
Publication Date:
12 November 2024
INQ0014365 – Pages 2 – 3 of email correspondence between Ian Harvey and Jane Hawdon, dated 08/09/2016
Source Date:
8 September 2016
Publication Date:
12 November 2024
INQ0015537 – Page 19 of handwritten notes of executive meeting, dated 08/09/2016
Source Date:
8 September 2016
Publication Date:
25 November 2024
INQ0006265 – Page 1 of handwritten notes of a meeting between hospital executives, prepared by Stephen Cross, dated 08/09/2016
Source Date:
8 September 2016
Publication Date:
26 November 2024
INQ0102274 – Pages 1 – 2 of Telephone Note of call between Ian Pace and Sue Hodkinson, dated 08/09/2016
Source Date:
8 September 2016
Publication Date:
26 November 2024
INQ0108406 – Pages 3 and 7 of Handwritten notes of Joshua Swash from the pre-inquest meeting about [Child A] dated 08/09/2016
Source Date:
8 September 2016
Publication Date:
28 November 2024
INQ0003123 – Page 1 of email correspondence between Ian Harvey and Jane Hawdon entitled ‘Case note review’, dated 08/09/2016
Source Date:
8 September 2016
Publication Date:
29 November 2024
INQ0051682 – Page 1 of document titled ‘NNU Options appraisal, dated 08/09/2016.
Source Date:
8 September 2016
Publication Date:
29 November 2024
INQ0002748 – Page 1 of email from Hayley Cooper to Tony Chambers and Sir Duncan Nichol, titled “Private and Confidential”, dated 08/09/2016
Source Date:
8 September 2016
Publication Date:
2 December 2024
INQ0108406 – Pages 3 – 5, 7 and 9 – 12 of Josh Swash’s note of pre-inquest meeting, dated 08/09/2016
Source Date:
8 September 2016
Publication Date:
4 December 2024
INQ0002860 – Email correspondence from Karen Rees to Alison Kelly and Sue Hodkinson, dated 09/09/2016
Source Date:
9 September 2016
Publication Date:
21 October 2024
INQ0002859 – email correspondence relating to Letby’s grievance, dated 09/09/2016
Source Date:
9 September 2016
Publication Date:
6 November 2024
INQ0103167 – Page 3 of email correspondence from Ravi Jayaram to consultants, dated 09/09/2016
Source Date:
9 September 2016
Publication Date:
13 November 2024
INQ0002860 – Page 1 of email from Karen Rees to Alison Kelly and Sue Hodkinson, titled ‘My view’, dated 09/09/2016
Source Date:
9 September 2016
Publication Date:
26 November 2024
INQ0015640 – Page 40 of handwritten note by Sue Hodkinson of executive meeting, dated 09/09/2016
Source Date:
9 September 2016
Publication Date:
26 November 2024
INQ0004340 – Handwritten notes of an executives meeting, dated 14/09/2016.
Source Date:
14 September 2016
Publication Date:
29 January 2025
INQ00178115 – Pages 1 – 2 and 5 of Minutes from Pan-Cheshire Child Death Overview Panel – Case Review Meeting, dated 16/09/2016
Source Date:
16 September 2016
Publication Date:
18 November 2024
INQ00178115 – Page 2 of Minutes from Pan-Cheshire Child Death Overview Panel – Case Review Meeting, dated 16/09/2016
Source Date:
16 September 2016
Publication Date:
20 November 2024
INQ0014687 – Page 7 of Minutes of the North Regional Quality Surveillance Group meeting, dated 16/09/2016
Source Date:
16 September 2016
Publication Date:
17 January 2025
INQ0098689 – Pages 1 – 4 of Speak Out Safely meeting, dated 19/09/2016
Source Date:
19 September 2016
Publication Date:
25 November 2024
INQ0004341 – Page 1 of meeting minutes of the Quality, Safety and Patient Experience Committee (QSPEC), dated 19/09/2016
Source Date:
19 September 2016
Publication Date:
29 November 2024
INQ0003178 – Pages 1 – 2 of minutes of the meeting held by the Quality, Safety & Patient Experience Committee, dated 19/09/2016
Source Date:
19 September 2016
Publication Date:
2 December 2024
INQ0003178 – Pages 1 – 2 of Minutes of the Quality, Safety & Patient Experience Committee, dated 19/09/2016
Source Date:
19 September 2016
Publication Date:
3 December 2024
INQ0103171 – Email from Stephen Brearey to Ian Harvey and colleagues, regarding case note review, dated 20/09/2016
Source Date:
20 September 2016
Publication Date:
19 November 2024
INQ0003133 – Page 2 of email correspondence from Ravi Jayaram to Tony Chambers entitled ‘Thank you’, dated 20/09/2016.
Source Date:
20 September 2016
Publication Date:
27 November 2024
INQ0103171 – Email from Stephen Brearey to Ian Harvey, entitled ‘Case Note reviews’ dated 20/09/2016
Source Date:
20 September 2016
Publication Date:
29 November 2024
INQ0002976 – Page 1 – 2 of email correspondence between Sue Hodkinson, Dee Appleton-Cairns and Alison Kelly, dated 21/09/2016
Source Date:
21 September 2016
Publication Date:
25 November 2024
INQ0052509 – Page 1 of Emails regarding independence of grievance investigation, dated 23/09/2016
Source Date:
23 September 2016
Publication Date:
2 September 2025
INQ0005564 – Pages 1 – 3 of Meeting minutes of Cheshire & Merseyside Clinical Effectiveness Group, relating to neonatal deaths and death of [Child O] & [Child P], dated 26/09/2016
Source Date:
26 September 2016
Publication Date:
17 October 2024
INQ0052593 – Page 1 of Email correspondence between Joshua Swash and Ian Harvey titled “NHS Confidential – Countess Inquest Information” dated 27/09/2016
Source Date:
27 September 2016
Publication Date:
28 November 2024
INQ0052593 – Pages 1 – 2 of email correspondence between Joshua Swash and Louis Browne and Ian Harvey, titled “NHS Confidential – Countess Inquest Information”, dated 27/09/2016
Source Date:
27 September 2016
Publication Date:
4 December 2024
INQ0052602 – email correspondence between Josh Swash and Louis Browne, titled “NHS Confidential – Inquest Documents”, dated 27/09/2016
Source Date:
27 September 2016
Publication Date:
4 December 2024
INQ0002042 – Page 155 - Letter from Pryers Solicitors LLP to HM Coroner Nicholas Rheinberg, dated 28/09/2016
Source Date:
28 September 2016
Publication Date:
4 November 2024
INQ0005279 – Page 2 of email correspondence between Dee Appleton-Cairns, Sue Hodkinson and Alison Kelly, titled “LL – brief”, dated 28/09/2016
Source Date:
28 September 2016
Publication Date:
26 November 2024
INQ0006862_0031 – Report from Dr J M Hawdon (Consultant Neonatologist, Royal Free NHS Foundation Trust) titled Advisory Medical Report, only.
Source Date:
1 October 2016
Publication Date:
18 September 2024
INQ0009618 – Pages 9 and 10 of Report from the Royal College of Paediatrics and Child Health, titled Service Review, dated October 2016
Source Date:
1 October 2016
Publication Date:
3 October 2024
INQ0009618 – Pages 14 and 25 of Royal College of Paediatrics and Child Health’s Service Review of the Countess of Chester Hospital, dated October 2016
Source Date:
1 October 2016
Publication Date:
7 November 2024
INQ0009618 – Page 25 of Report from the Royal College of Paediatrics and Child Health, titled Service Review, dated October 2016
Source Date:
1 October 2016
Publication Date:
11 November 2024
INQ0003172 – Pages 5 – 6, 17, 19, 22, 24, and 44 – 45 – Report by Dr Hawdon titled Advisory Medical Report, dated October 2016
Source Date:
1 October 2016
Publication Date:
12 November 2024
INQ0006765 – Pages 23 – 24 of Report from Dr J M Hawdon titled Advisory Medical Report, dated October 2016
Source Date:
1 October 2016
Publication Date:
12 November 2024
INQ0009618 – Page 21 of Report from the Royal College of Paediatrics and Child Health, titled Service Review, dated October 2016
Source Date:
1 October 2016
Publication Date:
18 November 2024
INQ0009618 – Page 9 of the Service Review of the Countess of Chester, completed by the Royal College of Paediatrics and Child Health, dated October 2016
Source Date:
1 October 2016
Publication Date:
21 November 2024
INQ0009619 – Pages 13, 20 and 22 – 24 of Royal College of Paediatrics and Child Health’s Service Review, dated October 2016
Source Date:
1 October 2016
Publication Date:
27 November 2024
INQ0006862 – Pages 54 – 55 of Dr Hawdon’s Advisory Medical Report, dated October 2016
Source Date:
1 October 2016
Publication Date:
27 November 2024
INQ0005273 – Pages 8-10 of a ‘draft for client review’ of the Service Review of the Countess of Chester, completed by the Royal College of Paediatrics and Child Health, dated October 2016
Source Date:
1 October 2016
Publication Date:
29 November 2024
INQ0060264 – Pages 1, 7 and 9 of a copy of the ‘Advisory Medical Report’ prepared by Dr Jane Hawdon, with Ian Harvey’s additional comments, dated October 2016
Source Date:
1 October 2016
Publication Date:
29 November 2024
INQ0002042 – Page 154 – Letter from HM Senior Coroner to Pryers Solicitors, dated 03/10/2016
Source Date:
3 October 2016
Publication Date:
6 December 2024
INQ0012066 – Pages 1 – 3 of Letter of instruction sent to Dr Jane Hawdon, dated 05/10/2016
Source Date:
5 October 2016
Publication Date:
12 November 2024
INQ0012066 – Page 1 of Letter to Dr Hawdon from Ian Harvey, dated 05/10/2016
Source Date:
5 October 2016
Publication Date:
4 December 2024
INQ0012066 – Page 1 – Letter to Dr Hawdon, dated 5 October 2016
Source Date:
5 October 2016
Publication Date:
6 December 2024
INQ0053069 – Pages 1 – 2 of email correspondence between Stephen Cross, Nicholas Rheinberg, Louis Browne and Joshua Swash, titled “[Child A] (deceased) Inquest”, dated 06/10/2016
Source Date:
6 October 2016
Publication Date:
4 December 2024
INQ0053069 – email correspondence from Stephen Cross to the Coroners Office, dated 06/10/2016
Source Date:
6 October 2016
Publication Date:
6 December 2024
INQ0009631 – Page 1 of Letter of instruction from Sue Eardley to Dr Wilson, dated 07/10/2016
Source Date:
7 October 2016
Publication Date:
11 November 2024
INQ0053104 – Page 1 of email correspondence between Hayley Griffiths (nee Cooper) and Chris Green, relating to Letby’s grievance investigation, dated 10/10/2016
Source Date:
10 October 2016
Publication Date:
6 November 2024
INQ0107909 – Pages 5 and 8 of Attendance note of a meeting between Mother A&B and Pryers Solicitors, dated 10/10/2016
Source Date:
10 October 2016
Publication Date:
13 November 2024
INQ0107909 – Page 8 of File Note for the inquest of [Child A], dated 10/10/2016
Source Date:
10 October 2016
Publication Date:
6 December 2024
INQ0003403 – Emails between Ian Harvey and Sue Eardley, dated between 10/10/2016 and 18/10/2016.
Source Date:
10 October 2016
Publication Date:
29 January 2025
INQ0003328 – Pages 1 – 2 of email correspondence to Dr Hawdon providing case notes, dated between 13/10/2016 and 14/10/2016
Source Date:
13 October 2016
Publication Date:
12 November 2024
INQ0002046 – Pages 82 – 83 – email correspondence between Christine Hurst and Nicholas Rheinberg, titled “[Child O] & [Child P]”, dated between 14/10/2016 and 17/10/2016
Source Date:
14 October 2016
Publication Date:
6 December 2024
INQ0102994 – Letter from Andrew Bibby to Alison Kelly, regarding issues facing the Neonatal Unit at the Countess of Chester Hospital, dated 16/10/2016.
Source Date:
16 October 2016
Publication Date:
16 January 2025
INQ0003167 – Pages 1 – 3 of Minutes of a Grievance Investigation Interview with Yvonne Griffiths relating to Lucy Letby grievance conducted by Dr Chris Green, dated 17/10/2016
Source Date:
17 October 2016
Publication Date:
16 October 2024
INQ0002879 – Pages 17 – 18 of Letby’s grievance file, including the grievance investigation interview conducted by Dr Chris Green, dated 18/10/2016
Source Date:
18 October 2016
Publication Date:
6 November 2024
INQ0003403 – Page 1 of email correspondence between Sue Eardley and Ian Harvey, entitled ‘RCPCH Review report draft’ dated 18/10/2016
Source Date:
18 October 2016
Publication Date:
29 November 2024
INQ0004349 – Letter from Dr Chris Green to Dr Stephen Brearey, regarding investigation meeting, dated 19/10/2016
Source Date:
19 October 2016
Publication Date:
19 November 2024
INQ0002988 – Page 2 of email correspondence between Kathryn de Beger, Sue Hodkinson and Alison Kelly, titled “Lucy Letby”, dated 19/10/2016
Source Date:
19 October 2016
Publication Date:
26 November 2024
INQ0004348 – Page 1 of Minutes of meeting of Executive Directors Group, dated 19/10/2016
Source Date:
19 October 2016
Publication Date:
26 November 2024
INQ0003370 – Meeting minutes of Executive team, dated 19/10/2016.
Source Date:
19 October 2016
Publication Date:
29 January 2025
INQ0002879 - Pages 21-24, 29-31 and 33-36 of Grievance Investigation Interview conducted by Dr Christopher Green with interviewees Alison Kelly, Sian Williams and Karen Rees, dated 20/10/2016
Source Date:
20 October 2016
Publication Date:
15 September 2025
INQ0003164 – Pages 1 – 3 of Minutes of a Grievance Investigation interview regarding Lucy Letby conducted by Dr Chris Green with Sian Williams, dated 20/10/2016
Source Date:
20 October 2016
Publication Date:
5 November 2024
INQ0002879 – Pages 21 – 22 and 24 of Grievance Investigation Interview by Dr Chris Green with Alison Kelly, dated 20/10/2016
Source Date:
20 October 2016
Publication Date:
25 November 2024
INQ0002879 – Pages 21-24 of Grievance Investigation Interview conducted by Dr Christopher Green with interviewee Alison Kelly, conducted on 20/10/2016, dated 14/11/2016
Source Date:
20 October 2016
Publication Date:
2 September 2025
INQ0002879 – Page 23 of Grievance Investigation Interview conducted by Dr Christopher Green with interviewee Alison Kelly, dated 20/10/2016
Source Date:
20 October 2016
Publication Date:
29 August 2025
INQ0002982 – Page 1 of email between Sue Hodkinson, Tony Millea, Alison Kelly, Colm Byrne, Karen Rees and Hayley Cooper, dated 20/10/2016
Source Date:
20 October 2016
Publication Date:
26 November 2024
INQ0002879 – Pages 25 – 27 – Grievance Investigation Interview by Dr Chris Green with Sue Hodkinson, dated 21/10/2016
Source Date:
21 October 2016
Publication Date:
26 November 2024
INQ0002879 – Page 26 – Grievance Investigation Interview conducted by Dr Chris Green with Sue Hodkinson, dated 21/10/2016
Source Date:
21 October 2016
Publication Date:
26 November 2024
INQ0068308 – Page 1 of email correspondence between Ravi Jayaram, Lucy Sementa and Chris Green relating to an investigation meeting, dated 24/10/2016
Source Date:
24 October 2016
Publication Date:
6 November 2024
INQ0008964 – Pages 81 – 82 – Letter from Sue Hodkinson to Letby, dated 25/10/2016
Source Date:
25 October 2016
Publication Date:
26 November 2024
INQ0002879 – Letter to Letby from Sue Hodkinson relating to a meeting held on 20th October 2016, dated 26/10/2016
Source Date:
26 October 2016
Publication Date:
17 October 2024
INQ0002879 – Pages 37-40 of Grievance Investigation Interview conducted by Dr Christopher Green with interviewee Eirian Powell, dated 28/10/2016 [removed from Thirlwall website]
Source Date:
28 October 2016
Publication Date:
15 September 2025
INQ0002879 – [Page 37] Grievance investigation interview, conducted by Dr Chris Green with Eirian Powell, dated 28/10/2016 [duplicate]
Source Date:
28 October 2016
Publication Date:
17 October 2024
INQ0003166 – Pages 1 – 2 and 4 of Minutes of a Grievance Investigation interview regarding Lucy Letby conducted by Dr Chris Green with Eirian Powell, dated 28/10/2016
Source Date:
28 October 2016
Publication Date:
17 October 2024
INQ0102271 – File note by Ian Pace regarding telephone call with Sue Hodkinson, dated 28/10/2016
Source Date:
28 October 2016
Publication Date:
2 September 2025
INQ0003358 – Page 1 – 2 of Letter from Dr Hawdon to Ian Harvey, dated 29/10/2016
Source Date:
29 October 2016
Publication Date:
12 November 2024
INQ0003358 – Pages 1 – 2 of Letter from Dr Hawdon to Ian Harvey, dated 29/10/2016
Source Date:
29 October 2016
Publication Date:
27 November 2024
INQ0003358 – Letter from Dr Hawdon to Ian Harvey, dated 29/10/2016.
Source Date:
29 October 2016
Publication Date:
29 January 2025
INQ0002046 – Pages 86 and 88 – email correspondence between Claire Raggett and Christine Hurst, titled “[Child O] & [Child P]”, dated between 31/10/2016 and 09/12/2016
Source Date:
31 October 2016
Publication Date:
6 December 2024
INQ0058202 – Page 3 of email correspondence between Christine Hurst and Claire Raggett, titled “[Child O] & [Child P]”, dated between 31/10/2016 and 07/12/2016
Source Date:
31 October 2016
Publication Date:
6 December 2024
INQ0002879 – Pages 5 – 6, 9, 17, 21 – 22, 29 – 30, 33, 37 – 38, 43 – 45, 47, 59, 63, 69, 83, 112 and 165 of Letby’s grievance file, dated November 2016
Source Date:
1 November 2016
Publication Date:
6 November 2024
INQ0016982 – Pages 1, 43 – 44 and 96 – 97 of Report from The Royal College of Pathologists titled Sudden Unexpected Death in Infancy and Childhood, Multi-Agency Guidelines for Care and Investigation, dated 01/11/2016
Source Date:
1 November 2016
Publication Date:
12 November 2024
INQ0001954 – Page 17 of the Royal College of Paediatrics and Child Health’s ‘Service Review Countess of Chester Hospital NHS Foundation Trust’, dated November 2016
Source Date:
1 November 2016
Publication Date:
19 November 2024
INQ0001954 – Pages 21 – 22 of the Royal College of Paediatrics and Child Health’s Service Review Countess of Chester Hospital NHS Foundation Trust, dated November 2016
Source Date:
1 November 2016
Publication Date:
20 November 2024
INQ0002048 – Page 93 of document titled ‘Observations additional to the RCPCH Review of Neonatal Services, dated November 2016
Source Date:
1 November 2016
Publication Date:
4 December 2024
INQ0003111 - Page 1-2 of Emails regarding the RCPCH report, dated between 01/11/2016 and 11/11/2016.
Source Date:
1 November 2016
Publication Date:
10 September 2025
INQ0003383 – Meeting minutes of Executive team, dated 02/11/2016.
Source Date:
2 November 2016
Publication Date:
29 January 2025
INQ0008605 – Page 7 of Letter from Doctor V regarding her involvement in the care of [Child O], dated 03/11/2016
Source Date:
3 November 2016
Publication Date:
7 October 2024
INQ0005341 – Page 3 of Email from Dr Chris Green to Dr Stephen Brearey and colleagues, regarding the grievance investigation, dated 03/11/2016
Source Date:
3 November 2016
Publication Date:
19 November 2024
INQ0003156 – Pages 1-3 of notes of an interview of Ian Harvey conducted by Dr Chris Green, dated 07/11/2016
Source Date:
7 November 2016
Publication Date:
29 November 2024
INQ0002879 – Pages 9-12 of Grievance Investigation Interview conducted by Dr Christopher Green with interviewee Ian Harvey, conducted on 07/11/2016, dated 14/11/2016
Source Date:
7 November 2016
Publication Date:
2 September 2025
INQ0003156 – Meeting minutes, dated 07/11/2016.
Source Date:
7 November 2016
Publication Date:
29 January 2025
INQ0054483 – email correspondence relating to a pre-meet prior to the grievance meeting of Letby, dated 08/11/2016
Source Date:
8 November 2016
Publication Date:
5 November 2024
INQ0002879 – Pages 47 – 49 and 51 – 52 of Letby’s grievance file, including the investigation interview with Ravi Jayaram and Stephen Brearey by Chris Green, dated 11/11/2016
Source Date:
11 November 2016
Publication Date:
6 November 2024
INQ0103176 – Pages 3 and 4 of investigation interview with Dr Stephen Brearey conducted by Chris Green, dated 11/11/2016
Source Date:
11 November 2016
Publication Date:
19 November 2024
INQ0008964 – Page 79 – 80 – Letter from Sue Hodkinson to Letby, dated 11/11/2016
Source Date:
11 November 2016
Publication Date:
26 November 2024
INQ0002879 – Pages 178, 218 and 221 of Letby’s grievance file, including the Investigation Report into the Grievance raised by Letby by Dr Chris Green, dated 12/11/2016
Source Date:
12 November 2016
Publication Date:
6 November 2024
INQ0003132 – Page 2 of email correspondence between Ian Harvey and Sue Eardley entitled ‘Amended Review’ dated 15/11/2016
Source Date:
15 November 2016
Publication Date:
29 November 2024
INQ0009617 – Page 1 of email correspondence between Ian Harvey and Sue Eardley, entitled ‘Amended Review’, dated between 15/11/2016 and 28/11/2016
Source Date:
15 November 2016
Publication Date:
29 November 2024
INQ0003132 – Emails between Ian Harvey, Sue Eardley and others, dated between 15/11/2016 and 31/01/2017
Source Date:
15 November 2016
Publication Date:
29 January 2025
INQ0009617- Emails between Ian Harvey and Sue Eardley, dated between 15/11/2016 and 28/11/2016.
Source Date:
15 November 2016
Publication Date:
29 January 2025
INQ0003373 – Page 1 of handwritten minutes of a meeting with Chris Green, dated 16/11/2016
Source Date:
16 November 2016
Publication Date:
6 November 2024
INQ0106988 – Pages 1 and 3 of Surveillance Report from NHS England relating to Regional Quality Surveillance Group Meeting, dated 16/11/2016
Source Date:
16 November 2016
Publication Date:
17 January 2025
INQ0017817 – Page 1 of Minutes from Pan-Cheshire Child Death Overview Panel Meetingl, dated 20/11/2016
Source Date:
20 November 2016
Publication Date:
18 November 2024
INQ0017817 – Page 2 of Minutes from Pan-Cheshire Child Death Overview Panel Meeting dated 20/11/2016
Source Date:
20 November 2016
Publication Date:
20 November 2024
INQ0002883 – Page 14 of ‘Report by Dr Christopher Green titled Grievance Investigation Report, dated 22/11/2016
Source Date:
22 November 2016
Publication Date:
29 August 2025
INQ0002879 – Page 222 – Investigation report into Letby’s grievance, dated 22/11/2016
Source Date:
22 November 2016
Publication Date:
25 November 2024
INQ0006346 – email correspondence between Hayley Griffiths (nee Cooper), Alison Kelly, Tony Chambers, Ian Harvey, Sue Hodkinson and Lorraine Burnett, dated 23/11/2016
Source Date:
23 November 2016
Publication Date:
6 November 2024
INQ0002884 – Email from Hayley Cooper to Ian Harvey, Alison Kelly, Tony Chambers and Sue Hodkinson, entitled ‘Private and Confidential’, dated 23/11/2016
Source Date:
23 November 2016
Publication Date:
26 November 2024
INQ0015641 – Page 26 of handwritten notes by Sue Hodkinson of meeting dated 24/11/2016
Source Date:
24 November 2016
Publication Date:
26 November 2024
INQ0003102 – Page 1 of Email from Dr Hawdon entitled “Post mortem reports” dated 25/11/2016
Source Date:
25 November 2016
Publication Date:
12 November 2024
INQ0103152 – Page 1 of email correspondence between Ian Harvey and Nim Subhedar titled “NNU review”, dated between 25/11/2016 and 01/12/2016
Source Date:
25 November 2016
Publication Date:
28 November 2024
INQ0009620 – Page 1 of a letter from the Royal College of Paediatrics and Child Health to Ian Harvey, dated 28/11/2016
Source Date:
28 November 2016
Publication Date:
29 November 2024
INQ0009620 – Page 1 of Letter from Dr David Shortland to Ian Harvey, dated 28/11/2016
Source Date:
28 November 2016
Publication Date:
12 December 2024
INQ0009620- Letter from Dr David Shortland to Ian Harvey, dated 28/11/2016.
Source Date:
28 November 2016
Publication Date:
29 January 2025
INQ0002447 – Page 6 of notes of Employer Link Service Meeting, dated 29/11/2016
Source Date:
29 November 2016
Publication Date:
13 December 2024
INQ0056138 – email correspondence attaching a draft letter for Letby, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
5 November 2024
INQ0056150 – email correspondence relating to a draft outcome letter for Letby’s grievance, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
5 November 2024
INQ0056174 – draft letter from Annette Weatherly to Letby relating to her grievance, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
5 November 2024
INQ0003155 – Pages 1 – 3, 5, 11, 15 and 17 of Minutes of the grievance hearing, conducted by Annette Weatherly, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
6 November 2024
INQ0003155 – Minutes of grievance hearing, chaired by Annette Weatherley, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
7 November 2024
INQ0056139 – Draft Letter from Annette Weatherley to Lucy Letby, regarding the outcome of the grievance investigation, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
7 November 2024
INQ0056151 – Pages 1 – 2 of Draft Letter from Annette Weatherley to Lucy Letby regarding the outcome of the grievance investigation, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
7 November 2024
INQ0056174 – Pages 2 – 3 of Draft Letter from Annette Weatherley to Lucy Letby regarding the outcome of the grievance investigation, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
7 November 2024
INQ0056176 – Pages 1 – 2 of Draft Letter from Annette Weatherley to Lucy Letby regarding the outcome of the grievance investigation, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
7 November 2024
INQ0108406 – Pages 9 – 10 and 12 of Notebook of Joshua Swash, dated between July and December 2016
Source Date:
1 December 2016
Publication Date:
13 November 2024
INQ0003158 – Page 2 of Letter from Annette Weatherley to Letby, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
25 November 2024
INQ0003158 – Page 3 of Letby’s grievance determination, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
25 November 2024
INQ0056172 – Page 1 of Draft Letter from Annette Weatherley to Letby, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
25 November 2024
INQ0003611 – Page 2 of a letter from Annette Weatherley to Lucy Letby, concerning the findings of Lucy Letby’s grievance, dated 01/12/2016
Source Date:
1 December 2016
Publication Date:
26 November 2024
INQ0003611 – Letter from Annette Weatherley to Lucy Letby, dated 01/12/2016.
Source Date:
1 December 2016
Publication Date:
29 January 2025
INQ0056173 – email correspondence relating to Letby’s grievance, dated 02/12/2016
Source Date:
2 December 2016
Publication Date:
5 November 2024
INQ0056171 – email correspondence from Alison Kelly to Mary Crocombe and Debra Cleverley, dated 02/12/2016
Source Date:
2 December 2016
Publication Date:
7 November 2024
INQ0056173 – email correspondence from Dee Appleton-Cairns to Annette Weatherley, relating to Letby’s grievance outcome, dated 02/12/2016
Source Date:
2 December 2016
Publication Date:
7 November 2024
INQ0056175 – email correspondence between Annette Weatherley and Dee Appleton-Cairns relating to Letby’s grievance outcome, dated 02/12/2016
Source Date:
2 December 2016
Publication Date:
7 November 2024
INQ0101999 – email correspondence between Dr McPartland, Dr Shukla and Dr Kokai, dated 06/12/2016
Source Date:
6 December 2016
Publication Date:
12 November 2024
INQ0014313 – Page 2 of Letter from Sue Hodkinson to Letby, dated 06/12/2016
Source Date:
6 December 2016
Publication Date:
25 November 2024
INQ0107844 – Page 1 of Email correspondence regarding Letby’s observation visits at Alder Hey Hospital, dated between 07/12/2016 and 08/12/2016
Source Date:
7 December 2016
Publication Date:
7 October 2024
INQ0107841 – Page 1 of Email correspondence regarding Letby’s observation visits at Alder Hey Hospital, dated 08/12/2016 and 09/12/2016
Source Date:
8 December 2016
Publication Date:
7 October 2024
INQ0107842 – Page 2 of email correspondence regarding Letby’s observation visits at Alder Hey Hospital, dated 08/12/2016 and 03/05/2017
Source Date:
8 December 2016
Publication Date:
7 October 2024
INQ0107832 – Page 1 of Letter from Human Resources at Alder Hey Hospital to Letby, dated 09/12/2016
Source Date:
9 December 2016
Publication Date:
7 October 2024
INQ0003094 – Letter from Ian Harvey to Dr Stephen Brearey, regarding draft report, dated 13/12/2016
Source Date:
13 December 2016
Publication Date:
19 November 2024
INQ0003094 – Page 1 of Letter from Ian Harvey to Stephen Brearey, dated 13/12/2016
Source Date:
13 December 2016
Publication Date:
26 November 2024
INQ0002899- Letter from Sue Hodkinson to Mr & Mrs Letby, dated 16/12/2016.
Source Date:
16 December 2016
Publication Date:
29 January 2025
INQ0102002 – Page 2 of email correspondence between Ian Harvey and Dr McPartland, dated 21/12/2016
Source Date:
21 December 2016
Publication Date:
12 November 2024
INQ0008077 – Page 1 of Letter from Alison Kelly to Andrew Bibby, regarding neonatal review update, dated 21/12/2016
Source Date:
21 December 2016
Publication Date:
25 November 2024
INQ0008077- Letter from Alison Kelly to Andrew Bibby regarding update on the Neonatal Review, dated 21/12/2016.
Source Date:
21 December 2016
Publication Date:
16 January 2025
INQ0017298 – Page 1 of agenda for engagement meeting between Care Quality Commission and Countess of Chester Hospital, dated 22/12/2016
Source Date:
22 December 2016
Publication Date:
5 November 2024
INQ0002912 – Page 3 – 6 of minutes of meeting at the Chief Executive office, dated 22/12/2016
Source Date:
22 December 2016
Publication Date:
26 November 2024
INQ0003463 – Minutes of a Meeting in Chief Executive’s Office, dated 22/12/2016
Source Date:
22 December 2016
Publication Date:
2 September 2025
INQ0002913 – Page 1 and 5 of minutes of meeting between Letby’s parents, Letby, Hayley Cooper, Karen Rees, Tony Chambers, Ian Harvey, Alison Kelly and Sue Hodkinson, dated 22/12/2016
Source Date:
22 December 2016
Publication Date:
28 November 2024
INQ0017298 – Agenda for engagement meeting between Care Quality Commission and Countess of Chester Hospital, regarding risk related to maternity / neonatal services, dated 22/12/2016
Source Date:
22 December 2016
Publication Date:
14 January 2025
INQ0004299 – Pages 1 – 3 of handwritten notes by Stephen Cross, dated 29/12/2016
Source Date:
29 December 2016
Publication Date:
2 December 2024
INQ0106817 - Page 13-14 of Handwritten Notes of Stephen Cross, dated 29/12/2016.
Source Date:
29 December 2016
Publication Date:
10 September 2025
INQ0004299- Handwritten meeting notes, dated between 29/12/2016 and 04/01/2017.
Source Date:
29 December 2016
Publication Date:
29 January 2025
INQ0004299 – Pages 1 – 3 of handwritten notes of a meeting, dated 30/12/2016
Source Date:
30 December 2016
Publication Date:
5 November 2024
INQ0004299 – Page 2 of Handwritten note of meeting dated 30/12/2016
Source Date:
30 December 2016
Publication Date:
27 November 2024
INQ0004299 – Page 3 of handwritten meeting notes, dated 30/12/2016.
Source Date:
30 December 2016
Publication Date:
27 November 2024
INQ0014771 – Page 4 – notes relating to Ian Harvey dated 03/01/2017
Source Date:
3 January 2017
Publication Date:
17 January 2025
INQ0008964 – Pages 49 – 50 – Letter from Sue Hodkinson to Letby, dated 04/01/2017
Source Date:
4 January 2017
Publication Date:
26 November 2024
INQ0057275 – Page 1 of email between Dee Appleton-Cairns and Sue Hodkinson, titled “Executive Directors Group – 04.01.17”, dated 04/01/2017
Source Date:
4 January 2017
Publication Date:
26 November 2024
INQ0107706 – Page 152 – Handwritten notes of Stephen Cross of a meeting, dated 05/01/2017 and 06/01/2017.
Source Date:
5 January 2017
Publication Date:
29 January 2025
INQ0012080 – Pages 1 – 2 of statement from Letby regarding her removal from the neonatal unit and grievance raised, dated 09/01/2017
Source Date:
9 January 2017
Publication Date:
8 October 2024
INQ0057493 – Statement from Lucy Letby relating to her removal from the neonatal unit on July 2016, dated 09/01/2017
Source Date:
9 January 2017
Publication Date:
6 November 2024
INQ0057494 – Statement from John and Susan Letby, parents of Lucy Letby, relating to Letby’s removal from the neonatal unit, dated 09/01/2017
Source Date:
9 January 2017
Publication Date:
6 November 2024
INQ0057497 – email correspondence between Hayley Griffiths (nee Cooper), Tony Chambers, Alison Kelly, Ian Harvey, Sue Hodkinson and Sir Duncan Nichol, dated 09/01/2017
Source Date:
9 January 2017
Publication Date:
6 November 2024
INQ0057499 – Email from Lucy Letby to Ian Harvey, entitled ‘Meeting information’, dated 09/01/2017
Source Date:
9 January 2017
Publication Date:
29 November 2024
INQ0057492 – Page 1 of email correspondence from Hayley Cooper, Tony Chambers, Alison Kelly, Ian Harvey, Sue Hodkinson, Sir Duncan Nichol and Karen Rees, titled “Private and Confidential Miss L Letby”, dated 09/01/2017
Source Date:
9 January 2017
Publication Date:
2 December 2024
INQ0057493 – Page 1 of statement by Letby, dated 09/01/2017
Source Date:
9 January 2017
Publication Date:
2 December 2024
INQ0003237 – Page 1 of minutes of an Extra-Ordinary Meeting of the Board of Directors of the Countess of Chester, dated 10/01/2017
Source Date:
10 January 2017
Publication Date:
26 November 2024
INQ0003237 – Page 4 of minutes of board meeting, dated 10/01/2017
Source Date:
10 January 2017
Publication Date:
26 November 2024
INQ0005340 – Pages 2 – 3, 5, 7 and 10 – Note of meeting between Tony Chambers, Alison Kelly, Letby, Karen Rees, Hayley Cooper dated 10/01/2017
Source Date:
10 January 2017
Publication Date:
26 November 2024
INQ0003237 – Pages 1- 2 of minutes of an Extra-Ordinary Meeting of the Board of Directors of the Countess of Chester, dated 10/01/2017.
Source Date:
10 January 2017
Publication Date:
27 November 2024
INQ0003518 – Page 1 of minutes of Extra-Ordinary Board of Directors Meeting (Private), dated 10/01/2017
Source Date:
10 January 2017
Publication Date:
27 November 2024
INQ0003518 – Pages 1 and 2 of Minutes of the Extra-ordinary Board of Directors Meeting dated 10/01/2017
Source Date:
10 January 2017
Publication Date:
28 November 2024
INQ0003239 – Document entitled ‘Review of Neonatal Services ad the Countess of Chester Hospital NHS FT’, prepared by Ian Harvey for an extraorindary meeting of the Board of Directors, dated 10/01/2017
Source Date:
10 January 2017
Publication Date:
29 November 2024
INQ0003237 – Pages 1 and 4 – 7 of minutes of meeting of Extra-Ordinary Board of Directors (Private), dated 10/01/2017
Source Date:
10 January 2017
Publication Date:
2 December 2024
INQ0003237 – Pages 1 – 6 of minutes of meeting of Extra-Ordinary Board of Directors, dated 10/01/2017
Source Date:
10 January 2017
Publication Date:
3 December 2024
INQ0003332 – Page 23 of handwritten notes of Extra-Ordinary Board meeting, dated 10/01/2017
Source Date:
10 January 2017
Publication Date:
3 December 2024
INQ0003518 – Pages 1 – 2 of minutes of Extra-Ordinary Board of Directors, dated 10/01/2017
Source Date:
10 January 2017
Publication Date:
3 December 2024
INQ0003237- Minutes of a meeting between Extra-Ordinary Board of Directors, regarding the outcome of the Royal College of Paediatrics and Child Health Report and the handling of the investigation into Letby, dated 10/01/2017.
Source Date:
10 January 2017
Publication Date:
16 January 2025
INQ0003332- Executive Board File Note, dated 10/01/2017.
Source Date:
10 January 2017
Publication Date:
29 January 2025
INQ0003135 – Pages 1 and 3 of email correspondence between Dr McPartland and Ian Harvey, dated between 11/01/2017 and 25/01/2017
Source Date:
11 January 2017
Publication Date:
12 November 2024
INQ0003135 – Emails between Ian Harvey, Jo McPartland and others, dated between 11/01/2017 and 25/01/2017
Source Date:
11 January 2017
Publication Date:
29 January 2025
INQ0004380- Handwritten meeting notes, dated 11/01/2017.
Source Date:
11 January 2017
Publication Date:
29 January 2025
INQ0002046 – Page 91 – email correspondence between Christine Hurst, Nicholas Rheinberg and Claire Raggett, titled “[Child O] & [Child P] (deceased)”, dated between 17/01/2017 and 20/01/2017
Source Date:
17 January 2017
Publication Date:
6 December 2024
INQ0002785- Letter from Ian Harvey to Lucy Letby, dated 17/01/2017.
Source Date:
17 January 2017
Publication Date:
29 January 2025
INQ0002919- Letter from Ian Harvey to Mr and Mrs Letby, dated 17/01/2017.
Source Date:
17 January 2017
Publication Date:
29 January 2025
INQ0058202 – Page 1 of email correspondence between Stephen Cross, Christine Hurst and various Countess of Chester staff, titled “[Child O] & [Child P]”, dated 20/01/2017
Source Date:
20 January 2017
Publication Date:
6 December 2024
INQ0102244 – email correspondence between Hayley Griffiths (nee Cooper), Alison Kelly and Sue Hodkinson, dated 24/01/2017
Source Date:
24 January 2017
Publication Date:
6 November 2024
INQ0102010 – email correspondence from Ian Harvey to Dr McPartland, dated 25/01/2017
Source Date:
25 January 2017
Publication Date:
12 November 2024
INQ0102280 – Page 1 of Ian Pace’s note of a call with Sue Hodkinson, dated 25/01/2017
Source Date:
25 January 2017
Publication Date:
21 November 2024
INQ0005795 – Page 1 of Email correspondence between Sue Hodkinson and Ian Harvey, titled “Private & Confidential – Grievance recommendations” dated 25/01/2017
Source Date:
25 January 2017
Publication Date:
26 November 2024
INQ0102217 – Page 1 of email correspondence from Ian Pace to Sue Hodkinson, dated 25/01/2017
Source Date:
25 January 2017
Publication Date:
26 November 2024
INQ0003135 – Page 1 of email correspondence between Jo McPartland and Ian Harvey, entitled ‘PM Reviews’, dated 25/01/2017
Source Date:
25 January 2017
Publication Date:
29 November 2024
INQ0102010 – Email from Ian Harvey to Jo McPartland, entitled ‘PM Reviews’, dated 25/01/2017
Source Date:
25 January 2017
Publication Date:
29 November 2024
INQ0003374 – Handwritten notes of Executive Team Meeting, dated 25/01/2017
Source Date:
25 January 2017
Publication Date:
29 January 2025
INQ0003523 – Pages 1 – 3 of minutes of meeting, chaired by Tony Chambers, regarding executive and paediatric consultant meeting, dated 26/01/2017
Source Date:
26 January 2017
Publication Date:
8 October 2024
INQ0003241 – Page 2 of Minutes of a Executive and Paediatric Consulting Meeting, dated 26/01/2017 [duplicated in INQ0003523?]
Source Date:
26 January 2017
Publication Date:
29 August 2025
INQ0058365 – Document containing draft email from Letby to colleagues, dated 26/01/2017
Source Date:
26 January 2017
Publication Date:
6 November 2024
INQ0102011 – email correspondence from Dr McPartland to Ian Harvey, dated 26/01/2017
Source Date:
26 January 2017
Publication Date:
12 November 2024
INQ0003523 – Pages 1 – 2 of Minutes of executive and paediatric consultant meeting, dated 26/01/2017
Source Date:
26 January 2017
Publication Date:
13 November 2024
INQ0003523 – Page 2 of Minutes of executive and paediatric consultant meeting, dated 26/01/2017
Source Date:
26 January 2017
Publication Date:
25 November 2024
INQ0003523 – Pages 1 – 2 of minutes of an Executive and Paediatric Consultant meeting, dated 26/01/2017
Source Date:
26 January 2017
Publication Date:
27 November 2024
INQ0102011 – Email from Jo McPartland to Ian Harvey, entitled ‘PM Reviews’, dated 26/01/2017
Source Date:
26 January 2017
Publication Date:
29 November 2024
INQ0002046 – Page 95 – email correspondence from Nicholas Rheinberg to Christine Hurst, titled “[Child O] & [Child P]”, dated 26/01/2017
Source Date:
26 January 2017
Publication Date:
6 December 2024
INQ0003489 – Pages 1 – 2 of Letter from Dr Tighe to Dr Jayaram, dated 29/01/2017
Source Date:
29 January 2017
Publication Date:
8 October 2024
INQ0003095 – Letter from Dr John Gibbs, Dr Ravi Jayaram, Doctor V and Dr Stephen Brearey, Dr Murthy Saladi, Dr Susie Holt, to Tony Chambers (Chief Executive), dated 30/01/2017
Source Date:
30 January 2017
Publication Date:
1 October 2024
INQ0003095 – Page 1 of Letter from Dr John Gibbs, Dr Ravi Jayaram, Doctor V, Dr Stephen Brearey, Dr Murthy Saladi and Dr Susie Holt, to Tony Chambers, dated 30/01/2017
Source Date:
30 January 2017
Publication Date:
13 November 2024
INQ0107706 – Pages 159-160 – Handwritten notes of Stephen Cross of a meeting, dated 30/01/2017 and 01/02/2017.
Source Date:
30 January 2017
Publication Date:
29 January 2025
INQ0058624 – email correspondence from Letby to all Countess of Chester Hospital neonatal unit staff, dated 31/01/2017
Source Date:
31 January 2017
Publication Date:
10 October 2024
INQ0058624 – Email correspondence from Letby to all Countess of Chester Neonatal Staff regarding her redeployment to the Unit and the outcome of the investigation, dated 31/01/2017
Source Date:
31 January 2017
Publication Date:
17 October 2024
INQ0058646 – email correspondence between Hayley Griffiths (nee Cooper), Letby and Sue Hodkinson, dated 31/01/2017
Source Date:
31 January 2017
Publication Date:
6 November 2024
INQ0058663 – Page 1 of email correspondence between Letby, NNU staff, Hayley Cooper, Sue Hodkinson and Alison Kelly, dated 31/01/2017 and 01/02/2017
Source Date:
31 January 2017
Publication Date:
26 November 2024
INQ0107734 – Pages 1 – 2 of email correspondence between Sue Hodkinson, Tony Chambers, Stephen Cross and Sir Duncan Nichol, titled “Private and confidential”, dated between 31/01/2017 and 01/02/2017
Source Date:
31 January 2017
Publication Date:
2 December 2024
INQ0004697 – Page 3 of Document titled Neonatal Unit Action Log, dated 01/02/2017
Source Date:
1 February 2017
Publication Date:
21 October 2024
INQ0002046 – Page 77 – email correspondence between Nicholas Rheinberg and Christine Hurst, titled “[Child O] & [Child P] (deceased)”, dated 01/02/2017
Source Date:
1 February 2017
Publication Date:
6 December 2024
INQ0103022 – Action Plan from the Countess of Chester Hospital relating to the Neonatal External Review, dated February 2017
Source Date:
1 February 2017
Publication Date:
17 January 2025
INQ0006421 – Handwritten notes of the Countess of Chester Hospital Executives Group meeting, dated 01/02/2017.
Source Date:
1 February 2017
Publication Date:
29 January 2025
INQ0003100 – Document entitled ‘Summary of Information for the Sunday Times’ dated 03/02/2017
Source Date:
3 February 2017
Publication Date:
29 November 2024
INQ0099055 – Page 1 of email correspondence from Ian Harvey to Dr Hawdon dated 05/02/2017
Source Date:
5 February 2017
Publication Date:
12 November 2024
INQ0005810 – Pages 1 – 2 of notes of a meeting held between Letby, Letby’s parents, Hayley Cooper, Karen Rees, Tony Chambers, Ian Harvey, Alison Kelly and Sue Hodkinson, dated 06/02/2017
Source Date:
6 February 2017
Publication Date:
21 October 2024
INQ0005810 – Page 3 of notes of a meeting held between Letby, Letby’s parents, Hayley Cooper, Karen Rees, Tony Chambers, Ian Harvey, Alison Kelly and Sue Hodkinson, dated 06/02/2017
Source Date:
6 February 2017
Publication Date:
26 November 2024
INQ0008964 – Pages 29 and 33 – minutes of meeting in Chief Executive Office, dated 06/02/2017
Source Date:
6 February 2017
Publication Date:
26 November 2024
INQ0014279 – Pages 1-7 of minutes of a meeting between Tony Chambers and other hospital executives, Letby, Letby’s parents and others, dated 06/02/2017.
Source Date:
6 February 2017
Publication Date:
27 November 2024
INQ0014279 – Pages 2 – 3 of notes of meeting between Letby’s parents, Letby, Hayley Cooper, Karen Rees, Tony Chambers, Ian Harvey, Alison Kelly and Sue Hodkinson, dated 06/02/2017″.
Source Date:
6 February 2017
Publication Date:
27 November 2024
INQ0014279 – Pages 1 and 3 of notes of a meeting held betweeen Ian Harvey, Karen Rees, Tony Chambers, Alison Kelly, Sue Hodkinson, Hayley Cooper, Lucy Letby and Lucy Letby’s parents, dated 06/02/2017
Source Date:
6 February 2017
Publication Date:
29 November 2024
INQ0106817 – Pages 31 – 32 and 34 of Stephen Cross’ notes, dated 06/02/2017
Source Date:
6 February 2017
Publication Date:
4 December 2024
INQ0003060 – Letter from Tony Chambers to colleagues, dated 06/02/2017
Source Date:
6 February 2017
Publication Date:
29 January 2025
INQ0003375 – Handwritten notes of meeting between various, dated 06/02/2017
Source Date:
6 February 2017
Publication Date:
29 January 2025
INQ0107706 – Pages 161-162 – Handwritten notes of Stephen Cross of an Executive Team meeting, dated 06/02/2017.
Source Date:
6 February 2017
Publication Date:
29 January 2025
INQ0107706 – Page 163 – Handwritten notes of Stephen Cross of a meeting with the Executive Team, dated 06/02/2017 and 07/02/2017.
Source Date:
6 February 2017
Publication Date:
29 January 2025
INQ0006078 – Page 1 of email chain between consultants entitled ‘Re: Letter from Tony Chambers’, dated 07/02/2017
Source Date:
7 February 2017
Publication Date:
7 October 2024
INQ0008969 – Pages 1 and 2 of a letter from Mother C to Ian Harvey, dated 07/02/2017
Source Date:
7 February 2017
Publication Date:
29 November 2024
INQ0058920 – Page 1 of email correspondence between Nim Subhedar and Ian Harvey, entitled ‘NNU review’, dated 07/02/2017
Source Date:
7 February 2017
Publication Date:
29 November 2024
INQ0014821 – Pages 9 – 10 of minutes of meeting of the Board of Directors, dated 07/02/2017
Source Date:
7 February 2017
Publication Date:
2 December 2024
INQ0106817 – Page 34 of handwritten notes by Stephen Cross of a meeting dated 07/02/2017
Source Date:
7 February 2017
Publication Date:
6 December 2024
INQ0004393 – Handwritten notes of various meetings, dated 07/02/2017
Source Date:
7 February 2017
Publication Date:
29 January 2025
INQ0107706 – Page 164 – Handwritten notes of Stephen Cross of a meeting with the Coroner and Medical Director, dated 07/02/2017 and 08/02/2017.
Source Date:
7 February 2017
Publication Date:
29 January 2025
INQ0012622 – Letter from Ian Harvey, dated 08/02/2017
Source Date:
8 February 2017
Publication Date:
5 November 2024
INQ0012619 – Template letter from Ian Harvey to parents dated 08/02/2017
Source Date:
8 February 2017
Publication Date:
29 November 2024
INQ0014411 – Template letter from Ian Harvey to parents dated 08/02/2017
Source Date:
8 February 2017
Publication Date:
29 November 2024
INQ0107964 – Page 213 – email correspondence between Sir Duncan Nichol and Ravi Jayaram titled “Review Report release”, dated 08/02/2017
Source Date:
8 February 2017
Publication Date:
2 December 2024
INQ0005815 – email correspondence from Christine Hurst to Stephen Cross, titled “Royal College report”, dated 08/02/2017
Source Date:
8 February 2017
Publication Date:
6 December 2024
INQ0006049 – Page 1 of Briefing from the Countess of Chester Hospital titled “Updated Position regarding neonatal services”, dated 08/02/2017
Source Date:
8 February 2017
Publication Date:
13 January 2025
INQ0004394 – Minutes of the Executive Directors Group meeting, dated 08/02/2017
Source Date:
8 February 2017
Publication Date:
29 January 2025
INQ0014644 – Page 1 of Update from Regional Specialised Commissioning Team, dated 09/02/2017
Source Date:
9 February 2017
Publication Date:
17 January 2025
INQ0003117 – Letter from Consultant Paediatricians including Dr Gibbs, Dr Jayaram, Doctor V, Doctor ZA, Dr Susie Holt, Dr Murthy Saladi and Dr Stephen Brearey to Tony Chambers (Chief Executive), regarding the Board’s findings and the RCPCH report, dated 10/02/2017
Source Date:
10 February 2017
Publication Date:
1 October 2024
INQ0103192 – Email from Dr Nimesh Subhedar to Ian Harvey, regarding NNU review, dated 10/02/2017
Source Date:
10 February 2017
Publication Date:
19 November 2024
INQ0003117 – Pages 1 – 2 of Letter from consultants to Tony Chambers, dated 10/02/2017
Source Date:
10 February 2017
Publication Date:
27 November 2024
INQ0006890 – Email correspondence between Ian Harvey and Nim Subhedar, entitled ‘NNU review’, dated 10/02/2017
Source Date:
10 February 2017
Publication Date:
29 November 2024
INQ0002048 – Pages 91 – 92 – Letter to Tony Chambers from consultant paediatricians, dated 10 February 2017
Source Date:
10 February 2017
Publication Date:
6 December 2024
INQ0002048 – Page 33 – Letter from HM Senior Coroner to Stephen Cross, dated 13/02/2017
Source Date:
13 February 2017
Publication Date:
6 December 2024
INQ0014376 – Pages 1 – 3 of Emails between Ian Harvey and Dr Hawdon dated 14/02/2017
Source Date:
14 February 2017
Publication Date:
12 November 2024
INQ0003379 – Page 1 of Stephen Cross’s handwritten notes of a meeting of hospital executives, dated 14/02/2017
Source Date:
14 February 2017
Publication Date:
25 November 2024
INQ0003379 – Handwritten minutes of meeting between various, dated 14/02/2017
Source Date:
14 February 2017
Publication Date:
29 January 2025
INQ0012756 - Email regarding consultant paediatrican's letter following the RCPCH and Hawdon reviews, dated 14/02/2017.
Source Date:
14 February 2017
Publication Date:
10 September 2025
INQ0002048 – Page 102 – Attendance Note of meeting between Nicholas Rheinberg, Alan Moore, Dr Harvey and Stephen Cross, dated 15/02/2017
Source Date:
15 February 2017
Publication Date:
29 November 2024
INQ0002048, p34, p89, p93 – letter dated 15/02/2017 sending RCPCH report to Rheinberg; RCPCH report (summary); document setting out the comments removed from RCPCH ‘copy for dissemination’ report
Source Date:
15 February 2017
Publication Date:
4 December 2024
INQ0002048 – Page 34 – Letter from Stephen Cross to HM Senior Coroner, dated 15/02/2017
Source Date:
15 February 2017
Publication Date:
6 December 2024
INQ0107706 – Pages 165-166 – Handwritten notes of Stephen Cross of a meeting on 15/02/2017
Source Date:
15 February 2017
Publication Date:
17 January 2025
INQ0006401 – Minutes of a meeting between executives, dated 15/02/2017
Source Date:
15 February 2017
Publication Date:
29 January 2025
INQ0003159 – Pages 1 – 2 of Letter from Tony Chambers to Dr Jayaram, regarding Royal College of Paediatrics and Child Health report, dated 16/02/2017
Source Date:
16 February 2017
Publication Date:
8 October 2024
INQ0006079 – Page 3 of email correspondence between neonatal consultants and Dr Tighe, dated 16/02/2017
Source Date:
16 February 2017
Publication Date:
8 October 2024
INQ0003159 – Page 1 of Letter from Tony Chambers to Dr Jayaram, dated 16/02/2017
Source Date:
16 February 2017
Publication Date:
13 November 2024
INQ0003159 – Pages 1 – 2 of Letter from Tony Chambers to Ravi Jayaram, dated 16/02/2017
Source Date:
16 February 2017
Publication Date:
27 November 2024
INQ0014405 – Page 1 of minutes of an ‘Engagement Meeting’ between Tony Chambers; Ian Harvey; Alison Kelly; Sian Williams and Ruth Millward of the Countess of Chester, with Jacqui Hornby and Debs Lindley of the CQC, dated 17/02/2017.
Source Date:
17 February 2017
Publication Date:
25 November 2024
INQ0017300 – Agenda for engagement meeting between Care Quality Commission and Countess of Chester Hospital, regarding the publication and actions arising from the neonatal services external Royal College of Paediatrics and Child Health review, dated 17/02/2017
Source Date:
17 February 2017
Publication Date:
14 January 2025
INQ0098375 - Minutes of Countess of Chester Hospital Speak Out Safely meeting, dated 20/02/2017.
Source Date:
20 February 2017
Publication Date:
12 September 2025
INQ0002653 – Pages 1 and 4 of minutes of the meeting held by the Quality, Safety & Patient Experience Committee, dated 20/02/2017
Source Date:
20 February 2017
Publication Date:
2 December 2024
INQ0098375 – Page 3 of Minutes of Countess of Chester Hospital Speak Out Safely meeting, dated 20/02/2017
Source Date:
20 February 2017
Publication Date:
3 December 2024
INQ0002048 – Page 103 – Letter from Nicholas Rheinberg to Stephen Cross, dated 21/02/2017
Source Date:
21 February 2017
Publication Date:
4 December 2024
INQ0004397 – Minutes of the Executive Directors Group meeting, dated 22/02/2017
Source Date:
22 February 2017
Publication Date:
29 January 2025
INQ0006081- File note detailing action notes from a progress meeting with Ian Harvey, Lesley Patel, Michael Gregory and Andrew Bibby, regarding Neonatal services at the Countess of Chester Hospital, dated 23/02/2017.
Source Date:
23 February 2017
Publication Date:
16 January 2025
INQ0014656 – Action notes of progress meeting between Ian Harvey, Lesley Patel, Michael Gregory and Andrew Bibby, regarding neonatal services at the Countess of Chester Hospital, dated 23/02/2017
Source Date:
23 February 2017
Publication Date:
16 January 2025
INQ0014656 – Page 1 of Action notes of progress meeting between Ian Harvey, Lesley Patel, Matthew Gregory and Andrew Bibby, regarding external review, staffing, culture and other issues of neonatal services at Countess of Chester Hospital, dated 23/02/2017
Source Date:
23 February 2017
Publication Date:
17 January 2025
INQ0006955 - Neonatal Review conducted by Dr John Gibbs and Ann Martyn, dated 24/02/2017.
Source Date:
24 February 2017
Publication Date:
12 September 2025
INQ0005336 – Pages 6 and 7 of email chain between John Gibbs, Stephen Brearey, Ravi Jayaram (Consultant Paediatricians), and colleagues, regarding their review of neonatal collapses, dated between 24/02/2017 and 19/03/2017
Source Date:
24 February 2017
Publication Date:
1 October 2024
INQ0014268 – Pages 1 – 2 of email correspondence between Gibbs, Jayaram and other paediatricians, titled “Discussion between John Gibbs and Ian Harvey 23/02/17”, dated between 24/02/2017 and 28/02/2017
Source Date:
24 February 2017
Publication Date:
4 December 2024
INQ0060238 – Email correspondence between Letby, Eirian Powell and Karen Rees relating to the off duty and doctor rota, dated 27/02/2017
Source Date:
27 February 2017
Publication Date:
17 October 2024
INQ0003187 – Letter from Consultant Paediatricians, including Dr Gibbs, Dr Stephen Brearey, Dr Ravi Jayaram, Dr Murthy Saladi, Doctor ZA and Dr Susie Holt to Lucy Letby, dated 28/02/2017
Source Date:
28 February 2017
Publication Date:
1 October 2024
INQ0003187 – Page 1 of Letter from Consultant Paediatric group to Letby, dated 28/02/2017
Source Date:
28 February 2017
Publication Date:
13 November 2024
INQ0006816 – Letter from Consultant Paediatricians at the Countess of Chester Hospital including Dr John Gibbs, Dr Ravi Jayaram, Doctor V, Dr Stephen Brearey, Dr Murthy Saladi, Doctor ZA and Dr Susie Holt to Tony Chambers (Chief Executive, Countess of Chester NHS Foundation Trust), regarding Royal College of Paediatrics and Child Health review, dated 01/03/2017
Publication Date:
1 October 2024
INQ0006424 – Page 2 of email correspondence from Ian Harvey to Ravi Jayaram, dated 01/03/2017
Publication Date:
13 November 2024
INQ0103207 – Email from Ian Harvey to Dr Stephen Brearey, regarding mediation with Lucy Letby, dated 01/03/2017
Publication Date:
19 November 2024
INQ0003119 – Page 2 of email correspondence between Ian Harvey and Ravi Jayaram, dated 01/03/2017
Publication Date:
25 November 2024
INQ0015641 – Page 111 of handwritten notes by Sue Hodkinson, dated 01/03/2017
Publication Date:
26 November 2024
INQ0006890 – Email from Ian Harvey to Stephen Brearey, entitled ‘NNU Meetings’ dated 01/03/2017
Publication Date:
29 November 2024
INQ0006105 – email correspondence between Dr Subhedar, Dr Gibbs, Dr Jayaram and Dr Brearey, dated between 02/03/2017 and 03/03/2017
Publication Date:
20 November 2024
INQ0003119 – Page 1 of email correspondence between Ravi Jayaram and Ian Harvey, entited ‘NNU Meetings’, dated 02/03/2017
Publication Date:
29 November 2024
INQ0006219 – Page 2 of email correspondence between Ian Harvey and Sue Hodkinson, titled “Strictly Private & Confidential – Without Prejudice”, dated between 05/03/2017 and 06/03/2017
Publication Date:
26 November 2024
INQ0003395 – Pages 2 and 3 of email chain requesting further reviews of [Child O], [Child P], [Child A], [Child I], [Child C] and [Child D], dated 06/03/2017
Publication Date:
3 October 2024
INQ0003395 – Page 1 of email correspondence from Ian Harvey to Stephen Brearey, dated 06/03/2017
Publication Date:
13 November 2024
INQ0003395 – email correspondence between Ian Harvey, Stephen Brearey and colleagues, dated 06/03/2017
Publication Date:
20 November 2024
INQ0003073 – Pages 1 and 2 of email correspondence between Stephen Brearey, Ian Harvey and others, entitled ‘Meeting summary from 28th Feb 2017’, dated 06/03/2017
Publication Date:
29 November 2024
INQ0012076 – Page 1 of letter from Dr McCormack to Letby, dated 08/03/2017
Publication Date:
8 October 2024
INQ0013059- Email between Fiona Reynolds and colleagues regarding CDOP Countess of Chester Hospital- Neonatal Review, dated 08/03/2017.
Publication Date:
14 January 2025
INQ0006432 – Page 1 of email correspondence between Stephen Brearey and Sue Hodkinson, titled “11.15 – Mediation”, dated 09/03/2017
Publication Date:
26 November 2024
INQ0011870 – Page 1 of email correspondence between Ravi Jayaram and Sue Hodkinson, titled “Mediation”, dated between 09/03/2017 and 13/03/2017
Publication Date:
26 November 2024
INQ0003219 – Page 1 of File note of a meeting between Ravi Jayaram and Sue Hodkinson, regarding Letby’s mediation, dated 15/03/2017
Source Date:
15 March 2017
Publication Date:
13 November 2024
INQ0003219 – Pages 1-2 of notes of a meeting between Ravi Jayaram and Sue Hodkinson, titled ‘File Note of from meeting with RJ 2.00pm-3.45pm’, dated 15/03/2017
Source Date:
15 March 2017
Publication Date:
26 November 2024
INQ0003219 – Pages 3 – 4 of File Note of meeting between Sue Hodkinson and Ravi Jayaram, dated 15/03/2017
Source Date:
15 March 2017
Publication Date:
26 November 2024
INQ0003344 – Pages 1 – 3 of Handwritten notes of an executives meeting, dated 16/03/2017
Source Date:
16 March 2017
Publication Date:
25 November 2024
INQ0003344 – Pages 1 and 3 of handwritten note, dated 16/03/2017
Source Date:
16 March 2017
Publication Date:
25 November 2024
INQ0003344 – Page 3 of handwritten note of meeting between executives, dated 16/03/2017
Source Date:
16 March 2017
Publication Date:
27 November 2024
INQ0003344 – Pages 1 – 2 of Stephen Cross’ handwritten meeting notes dated 16/03/2017
Source Date:
16 March 2017
Publication Date:
3 December 2024
INQ0003344 – Handwritten notes of an executives meeting, dated 16/03/2017.
Source Date:
16 March 2017
Publication Date:
29 January 2025
INQ0003344 – Handwritten notes of a meeting, dated 16/03/2017
Source Date:
16 March 2017
Publication Date:
13 May 2025
INQ0108368 – Whatsapp messages between Hayley Griffiths (nee Cooper) and Letby, dated between 18/03/2017 and 20/06/2018
Source Date:
18 March 2017
Publication Date:
6 November 2024
INQ0107706 – Page 167 – Handwritten notes of Stephen Cross of an Executive Team meeting, dated 20/03/2017
Source Date:
20 March 2017
Publication Date:
29 January 2025
INQ0004402 – Page 1 of Minutes of the Executive Team meeting, dated 22/03/2017
Source Date:
22 March 2017
Publication Date:
26 November 2024
INQ0003471 – Page 1 of Letter from Sue Hodkinson to Letby, summarising meetings which took place between 10 January 2017 and 22 March 2017, dated 24/03/2017
Source Date:
24 March 2017
Publication Date:
21 October 2024
INQ0001953 – Pages 1, 3 and 10 of Minutes from Pan Cheshire Child Death Overview Panel, dated 24/03/2017
Source Date:
24 March 2017
Publication Date:
18 November 2024
INQ0012008 – Pages 1, 3 and 10 of Minutes from Pan Cheshire Child Death Overview Panel Meeting, dated 24/03/2017
Source Date:
24 March 2017
Publication Date:
18 November 2024
INQ0001953 – Page 3 and 10 of Minutes of a meeting between Pan Cheshire Child Death Overview Panel, dated 24/03/2017
Source Date:
24 March 2017
Publication Date:
20 November 2024
INQ0012008 – Page 3 of Minutes of the Pan Cheshire Child Death Overview Panel Meeting, dated 24/03/2017
Source Date:
24 March 2017
Publication Date:
20 November 2024
INQ0003471 – Letter from Sue Hodkinson to Lucy Letby, dated 24/03/2017
Source Date:
24 March 2017
Publication Date:
29 January 2025
INQ0101093 – Email correspondence from Dr McGuigan regarding his opinions on a police led investigation, dated 26/03/2017
Source Date:
26 March 2017
Publication Date:
8 October 2024
INQ0003150 – Page 1 of Minutes of a Paediatrics meeting, regarding unexplained deaths on the neonatal unit, dated 27/03/2017
Source Date:
27 March 2017
Publication Date:
13 November 2024
INQ0003150 – Pages 1 – 4 of Paediatrics meeting, dated 27/03/2017
Source Date:
27 March 2017
Publication Date:
13 November 2024
INQ0004407 – Pages 1 – 2 of minutes of meeting between CoCH exectuive and paediatric counsultants, dated 27/03/2017
Source Date:
27 March 2017
Publication Date:
19 November 2024
INQ0004406 – Pages 1 – 2 of minutes of a Paediatrics Meeting held between Tony Chambers, Ian Harvey, Sue Hodkinson, Ravi Jayaram, Steve Brearey, Julie Maddocks, and Nim Subhedar, dated 27/03/2017
Source Date:
27 March 2017
Publication Date:
26 November 2024
INQ0003150 – Pages 1, 2 and 6 of Paediatrics Meeting on 27/03/2017
Source Date:
27 March 2017
Publication Date:
27 November 2024
INQ0003150 – Pages 1 – 2 and 4 – 5 of meeting note of Paediatrics Meeting, dated 27/03/2017
Source Date:
27 March 2017
Publication Date:
28 November 2024
INQ0003150 – Pages 1 – 6 of a note of a ‘Paediatrics Meeting’ [dated 27/03/2017]
Source Date:
27 March 2017
Publication Date:
29 November 2024
INQ0014281 – Page 1 of handwritten note of meeting, dated 28/03/2017
Source Date:
28 March 2017
Publication Date:
26 November 2024
INQ0014281 – Handwritten note of meeting of board members, dated 28/03/2017
Source Date:
28 March 2017
Publication Date:
27 November 2024
INQ0107706 – Page 169 – Handwritten notes of Stephen Cross of a meeting, dated 28/03/2017.
Source Date:
28 March 2017
Publication Date:
29 January 2025
INQ0014651 – Email chain between Margaret Kitchen and Robert Cornall, regarding an email about the Neonatal deaths at the Countess of Chester, dated between 29/03/2017 and 04/04/2017.
Source Date:
29 March 2017
Publication Date:
16 January 2025
INQ0103060- Email chain between Michael Gregory and colleagues regarding concerns about the Neonatal Unit, dated between 29/03/2017 and 11/04/2017.
Source Date:
29 March 2017
Publication Date:
16 January 2025
INQ0014651 – Pages 1 – 2 of email correspondence between Margaret Kitching and Robert Cornall titled ‘Countess of Chester, dated between 29/03/2017 and 04/04/2017
Source Date:
29 March 2017
Publication Date:
17 January 2025
INQ0005850 – Page 3 of email correspondence from Ravi Jayaram to Sue Hodkinson, relating to concerns on the neonatal unit, dated 30/03/2017
Source Date:
30 March 2017
Publication Date:
13 November 2024
INQ0101944 - Handwritten Notes of Sue Hodkinson, [of call with Corinne Slingo regarding concerns surrounding neonatal death], dated 30/03/2017
Source Date:
30 March 2017
Publication Date:
15 September 2025
INQ0011817 – Pages 3 – 4 of Email correspondence between Ravi Jayaram and Sue Hodkinson, titled ‘Concerns’, dated between 30/03/2017-11/05/2017
Source Date:
30 March 2017
Publication Date:
26 November 2024
INQ0064897 – Page 1 of email correspondence between Ravi Jayaram and Sue Hodkinson, titled ‘Re: dates’, dated 30/03/2017
Source Date:
30 March 2017
Publication Date:
26 November 2024
INQ0002926 – Page 1 of document titled Neonatal Unit – Timeline, dated 31/03/2017
Source Date:
31 March 2017
Publication Date:
21 November 2024
INQ0008961 – Letby’s reflection on a drug error, dated April 2016
Publication Date:
16 October 2024
INQ0003124- Pages 1 – 2 of Emails between Ian Harvey and Dr Hawdon dated April 2017
Publication Date:
12 November 2024
INQ0003529 – Page 3 – 5 and 9 of letter from Sue Hodkinson to Letby, summarising meetings that took place between 10 January 2017 until 30 March 2017, dated 03/04/2017
Publication Date:
21 October 2024
INQ0003226 – Page 1 of document produced by Stephen Cross titled ‘Rationale’, dated 03/04/2017
Publication Date:
21 November 2024
INQ0088716 – Pages 1 and 2 of Emails between Debra Cleverley, Stephen Cross and Simon Medland QC, regarding papers and arranging a meeting with Sir Duncan Nichol, Tony Chambers , Ian Harvey and Stephen Cross, dated 03/04/2017
Publication Date:
21 November 2024
INQ0005340 – Page 10 of a Letter from Sue Hodkinson to Letby enclosing meeting notes, dated 03/04/2017
Publication Date:
26 November 2024
INQ0006123 – Document entitled ‘Rationale’ prepared by Stephen Cross, dated 03/04/2017
Publication Date:
29 November 2024
INQ0014378 – Pages 1 and 2 of a documentg produced by Ian Harvey entitled ‘Neonatal Services at the Countess of Chester Hospital NHS FT Summary’, dated 03/04/2017
Publication Date:
29 November 2024
INQ0103211 – Page 1 of email correspondence between Stephen Brearey and Ian Harvey, dated between 04/04/2017 and 05/04/2017
Publication Date:
13 November 2024
INQ0003351 – Page 1 of handwritten note of meeting between Duncan Nichol, Tony Chambers, Ian Harvey, Stephen Cross and Simon Medland, dated 04/04/2017
Publication Date:
21 November 2024
INQ0101937 – email correspondence between Corinne Slingo, Cheryl Rowbotham and Sue Hodkinson, dated 04/04/2017
Publication Date:
21 November 2024
INQ0103065- Email from Michael Gregory to Kieran Murphy regarding update on the Countess of Chester Hospital, dated 04/04/2017.
Publication Date:
16 January 2025
INQ0003088 – Emails between Sue Hodkinson and Corinne Slingo, dated 04/04/2017
Publication Date:
29 January 2025
INQ0003477 – Pages 1 – 2 of Letter from Sue Hodkinson to Letby, dated 05/04/2017
Publication Date:
26 November 2024
INQ0003126 – Email from Michael Gregory to Ian Harvey, regarding neonatal services, dated 05/04/2017
Publication Date:
16 January 2025
INQ0103061- Email chain between Michael Gregory and Ian Harvey regarding the Review of the Neonatal Unit, dated between 05/04/2017 and 11/04/2017.
Publication Date:
16 January 2025
INQ0103067 – Email chain between Margaret Kitching and Michael Gregory regarding review of Neonatal serivices and meeting with Ian Harvey, dated between 05/04/2017 and 11/04/2017.
Publication Date:
16 January 2025
INQ0107706 – Page 170 – Handwritten notes of Stephen Cross of a meeting, dated 05/04/2017.
Publication Date:
29 January 2025
INQ0103066 – Email chain between Alison Kelly, Lesley Patel and Michael Gregory regarding Countess of Chester Hospital Neonatal Unit Action Plan, dated 06/04/2017.
Publication Date:
16 January 2025
INQ0103062- Email chain between Michael Gregory and Margaret Kitching regarding the Neonatal Services Review, dated 10/04/2017.
Source Date:
10 April 2017
Publication Date:
16 January 2025
INQ0103028 – Email chain between various, regarding the Royal College of Paediatrics and Child Health report into the Countess of Chester Hospital, dated 10/04/2017
Source Date:
10 April 2017
Publication Date:
17 January 2025
INQ0103063 – Email chain between Michael Gregory and Lesley Patel regarding RCPCH Report, dated 11/04/2017.
Source Date:
11 April 2017
Publication Date:
16 January 2025
INQ0107706 – Page 172 – Handwritten notes of Stephen Cross of a meeting, dated 11/04/2017 and 12/04/2017.
Source Date:
11 April 2017
Publication Date:
29 January 2025
INQ0005857 – Page 1 of Minutes of Meeting between Simon Medland QC and Consultant Paediatricians at the Countess of Chester Hospital, dated 12/04/2017
Source Date:
12 April 2017
Publication Date:
13 November 2024
INQ0005857 – Pages 1 – 5 of Minutes of meeting between Simon Medland QC and consultants, dated 12/04/2017
Source Date:
12 April 2017
Publication Date:
19 November 2024
INQ0003091 – Pages 1 – 2 and 6 of minutes of a meeting between Simon Medland QC and certain consultants, dated 12/04/2017
Source Date:
12 April 2017
Publication Date:
21 November 2024
INQ0006136 – Emails between Ravi Jayaram (Consultant Paediatrician, Countess of Chester Hospital), Ian Harvey (Medical Director, Countess of Chester Hospital) and colleagues, dated between 13/04/2017 and 24/04/2017
Source Date:
13 April 2017
Publication Date:
1 October 2024
INQ0006136 – Page 1 of email correspondence between Ravi Jayaram, Ian Harvey and colleagues, dated between 13/04/2017 and 24/04/2017
Source Date:
13 April 2017
Publication Date:
13 November 2024
INQ0103217 – Email chain between Susie Holt, John Gibbs, Stephen Brearey and colleagues, dated between 13/04/2017 and 19/04/2017
Source Date:
13 April 2017
Publication Date:
19 November 2024
INQ0003236 – Pages 1 – 6 – Minutes of meeting of Extra-Ordinary Board of Directors, held in private, regarding the ongoing investigation into the mortality rates , dated 13/04/2017
Source Date:
13 April 2017
Publication Date:
21 November 2024
INQ0006136 – Page 1 of Emails between Ravi Jayaram, Ian Harvey and colleagues, dated between 13/04/2017 and 24/04/2017
Source Date:
13 April 2017
Publication Date:
21 November 2024
INQ0003124 – Page 2 of email correspondence between Jane Hawdon and Ian Harvey, titled “Countess of Chester update”, dated 13/04/2017
Source Date:
13 April 2017
Publication Date:
27 November 2024
INQ0003236 – Pages 1 and 3 of minutes of ‘Extra-Ordinary Board of Directors (Private)’ meeting, dated 13/04/2017
Source Date:
13 April 2017
Publication Date:
29 November 2024
INQ0003236 – Pages 1 – 3 and 5 – 6 of minutes of meeting of Extra-Ordinary Board of Directors (Private), dated 13/04/2017
Source Date:
13 April 2017
Publication Date:
2 December 2024
INQ0003236 – Page 1 and 5 of Minutes of a meeting between Extra-Ordinary Board of Directors, dated 13/04/2017
Source Date:
13 April 2017
Publication Date:
3 December 2024
INQ0003124 – Emails between Jane Hawdon and Ian Harvey, dated between 13/04/2017 and 18/04/2017.
Source Date:
13 April 2017
Publication Date:
29 January 2025
INQ0101342 – Text messages between Kathryn de Beger and Letby, dated 16/04/2017 and 27/04/2017
Source Date:
16 April 2017
Publication Date:
9 October 2024
INQ0102758 – Pages 1 – 4 of Emails between Debbie Dodd, Nigel Wenham, Anne Mckenzie and Hayley Frame, relating to CDOP, dated between 19/04/2017 and 21/04/2017
Source Date:
19 April 2017
Publication Date:
20 November 2024
INQ0008971 – Letter from Mother C to Ian Harvey, dated 19/04/2017
Source Date:
19 April 2017
Publication Date:
29 November 2024
INQ0101091 – Handwritten notes of a Executive Directors Meeting dated 19/04/2017
Source Date:
19 April 2017
Publication Date:
29 November 2024
INQ0014660 – Emails between various, regarding escalation options/potential notification to Police, dated 19/04/2017
Source Date:
19 April 2017
Publication Date:
16 January 2025
INQ0014664 – Emails between various, regarding update from the Countess of Chester Hospital, dated 19/04/2017
Source Date:
19 April 2017
Publication Date:
16 January 2025
INQ0014667- Email chain between Margaret Kitching and Michael Gregory regarding update on the Neonatal Review, dated 19/04/2017.
Source Date:
19 April 2017
Publication Date:
16 January 2025
INQ0014660 – Page 1 of email correspondence between Michael Gregory, Ian Harvey and Lesley Patel, titled ‘Update on Chester’, dated 19/04/2017
Source Date:
19 April 2017
Publication Date:
17 January 2025
INQ0107706 – Page 173 – Handwritten notes of Stephen Cross of a meeting, dated 21/04/2017 and 25/04/2017.
Source Date:
21 April 2017
Publication Date:
29 January 2025
INQ0098376 – Page 1 of Minutes of Freedom to Speak Up Meeting, dated 24/04/2017
Source Date:
24 April 2017
Publication Date:
25 November 2024
INQ0098434 – Pages 1 – 2 of Minutes of Freedom to Speak Up Meeting, dated 24/04/2017
Source Date:
24 April 2017
Publication Date:
25 November 2024
INQ0098434 – Page 4 of Minutes of a Speak Out Safely Meeting, dated 24/04/2017
Source Date:
24 April 2017
Publication Date:
29 August 2025
INQ0063777 – Email correspondence between Kathryn De Beger and Letby, regarding concerns on the neonatal unit, dated 25/04/2017
Source Date:
25 April 2017
Publication Date:
9 October 2024
INQ0014672 – Emails between various, regarding potential notification to Police, dated between 25/04/2017 and 26/04/2017
Source Date:
25 April 2017
Publication Date:
16 January 2025
INQ0014673 – Emails between various, regarding response from Ian Harvey and involvement of the Child Death Overview Panel and Police, dated between 25/04/2017 and 26/04/2017
Source Date:
25 April 2017
Publication Date:
16 January 2025
INQ0014673 – Pages 1 – 3 of email correspondence between Margaret Kitching, Richard Barker and colleagues, titled ‘Response from Ian Harvey’, dated 26/04/2017
Source Date:
26 April 2017
Publication Date:
17 January 2025
INQ0102292 – Notes from Stephen Cross of a meeting between Doctors and Executives, dated 27/04/2017
Source Date:
27 April 2017
Publication Date:
20 November 2024
INQ0008964 – Pages 7 – 8 of Letter from Sue Hodkinson to Letby, dated 27/04/2017
Source Date:
27 April 2017
Publication Date:
26 November 2024
INQ003193 – Minutes of a conference call meeting between the Countess of Chester Hospital, NHS England and NHS Improvement, regarding overview of deaths, dated 27/04/2017
Source Date:
27 April 2017
Publication Date:
16 January 2025
INQ0014674 – Email from Michael Gregory to Teresa Fenech and colleagues regarding update call with the Countess of Chester Hospital NHS Foundation Trust, dated 27/04/2017.
Source Date:
27 April 2017
Publication Date:
16 January 2025
INQ0103003 – Email from Robert Cornall to Margaret Kitching, regarding Ian Harvey’s response to a meeting in relation to the Child Death Overview Panel, dated 27/04/2017.
Source Date:
27 April 2017
Publication Date:
16 January 2025
INQ0003193 – Page 1 of minutes of a conference call meeting between the Countess of Chester Hospital, NHS England and NHS Improvement, regarding overview of deaths, dated 27/04/2017
Source Date:
27 April 2017
Publication Date:
17 January 2025
INQ0005461 – Minutes of a meeting between Ian Harvey, Nigel Wenham, Margaret Kitching and Vince Connolly, dated 27/04/2017.
Source Date:
27 April 2017
Publication Date:
29 January 2025
INQ0008973 – Letter from Ian Harvey to Mother C, dated 28/04/2017
Source Date:
28 April 2017
Publication Date:
29 November 2024
INQ0005077 – Emails between Margaret Kitching and Ian Harvey, regarding actions from recent conference call and update on discussions with the Police, dated between 28/04/2017 and 05/05/2017
Source Date:
28 April 2017
Publication Date:
16 January 2025
INQ0106994 – Emails between various, regarding update on Police investigation and information sharing, dated between 28/04/2017 and 05/05/2017
Source Date:
28 April 2017
Publication Date:
16 January 2025
INQ0107706 – Page 174 – Handwritten notes of Stephen Cross of a meeting, dated 28/04/2017 and 02/05/2017
Source Date:
28 April 2017
Publication Date:
29 January 2025
INQ0108367 – Pages 1, 12 and 15 of Guidance from the General Pharmaceutical Council titled Standards for pharmacy professionals, dated May 2017
Publication Date:
6 November 2024
INQ0102319 – Letter to Chief Constable Byrne from Tony Chambers, dated 02/05/2017
Publication Date:
20 November 2024
INQ0003517 – Pages 1 – 2 of Minutes of extra-ordinary board of directors meeting, dated 02/05/2017
Publication Date:
2 December 2024
INQ0004221 – Minutes of a meeting between the Extra-Ordinary Board Meeting, dated 02/05/2017.
Publication Date:
29 January 2025
INQ0002048 – Page 110 – email between Alan Moore and Aaron Duggan, titled “Letter to Chief Constable, Simon Byrne”, dated 03/05/2017
Publication Date:
4 December 2024
INQ0002045 – Page 974 – Letter from HM Senior Coroner to Stephen Cross, dated 03/05/2017
Publication Date:
6 December 2024
INQ0002797 – Page 4 – Note of meeting between Alison Kelly, Letby, Karen Rees, Hayley Cooper, Kathryn de Beger and Sue Hodkinson, dated 04/05/2017
Publication Date:
26 November 2024
INQ0014676 – Page 1 of email correspondence between Margaret Kitching and Ian Harvey titled ‘Conference call notes (with logos)’, dated between 04/05/2017 and 05/05/2017
Publication Date:
17 January 2025
INQ0002931 – Pages 1 – 2 of Letter from Sue Hodkinson to Ravi Jayaram, enclosing meeting minutes, dated 5 May 2017
Publication Date:
26 November 2024
INQ0102298 Pages 3 – 4 of Meeting between Cheshire Constabulary, Tony Chambers, Stephen Cross and Ian Harvey, on 05/05/2017
Publication Date:
27 November 2024
INQ0003077 – Minutes of a meeting involving Cheshire Constabulary, dated 05/05/2017.
Publication Date:
29 January 2025
INQ0008615 – Pages 1 – 2 of Datix form relating to [Child O], dated 08/05/2017
Publication Date:
17 October 2024
INQ0014827 – Handwritten Executive Meeting Minutes, dated 08/05/2017.
Publication Date:
29 January 2025
INQ0012683 – Pages 2-3 – Email from Margaret Kitching to various, regarding update from the Countess of Chester Hospital in relation to the Police investigation, dated 09/05/2017.
Publication Date:
16 January 2025
INQ0011915 – Page 1 of Document titled Reasons for concerns regarding a possible criminal cause for increased neonatal mortality at the Countess of Chester Hospital NHS Foundation Trust June 2015-July 2016, dated 10/05/2017
Publication Date:
19 November 2024
INQ0102300 – Pages 3 – 4 of Emails between Dr Ravi Jayaram and Nigel Wenham, dated 10/05/2017
Publication Date:
20 November 2024
INQ0102301 – Document titled ‘Reasons for concerns regarding a possible criminal cause for increased neonatal mortality at the Countess of Chester… June 2015 – July 2016’, dated 10/05/2017
Publication Date:
20 November 2024
INQ0003671 – Pages 1 – 3 of Document titled Reasons for concerns regarding a possible criminal cause for increased neonatal mortality at the Countess of Chester Hospital NHS Foundation Trust, June 2015 – July 2016, dated 10/05/2017
Publication Date:
27 November 2024
INQ0015642 – Page 48 of handwritten note by Sue Hodkinson of meeting with Tony Chambers, dated 12/05/2017
Publication Date:
26 November 2024
INQ0003076 – Page 6 of Meeting between Cheshire Constabulary, Tony Chambers, Stephen Cross and Ian Harvey, on 12/05/2017
Publication Date:
27 November 2024
INQ0003076 – Pages 1 – 2, 4 – 8 and 10 of meeting between Cheshire Constabulary and Tony Chambers, Ian Harvey and Stephen Cross, dated 12/05/2017
Publication Date:
28 November 2024
INQ0003076 – Pages 5, 6 and 8 of minutes of a meeting between Cheshire Constabulary and the Countess of Chester Hospital, dated 12/05/2017
Publication Date:
29 November 2024
INQ0014678 – Page 1 of Email from Ian Harvey to Margaret Kitching, titled ‘Update’, dated 12/05/2017
Publication Date:
29 November 2024
INQ0106995 – Emails between Ian Harvey and Margaret Kitching, regarding discussions with Police in relation to a potential investigation, dated 12/05/2017
Publication Date:
16 January 2025
INQ0003076 – Meeting minutes of Operation Hummingbird, dated 12/05/2017.
Publication Date:
29 January 2025
INQ0102306 – Pages 2, 4 – 9 of Notes of meeting between Cheshire Police, including Nigel Wenham and Executives, dated 12/05/2017.
Publication Date:
17 February 2025
INQ0102309 – Pages 2 – 7 of Notes of a meeting between Nigel Wenham and senior clinicians, dated 15/05/2017
Publication Date:
20 November 2024
INQ0101349 – Email from Margaret Kitching to colleagues, regarding brief received from Ian Harvey on status of Police investigation and next steps, dated 15/05/2017
Publication Date:
16 January 2025
INQ0017303 – Email from Lorraine Bolam to Ellen Armistead, Jacqueline Hornby, and Deborah Lindley, regarding the Countess of Chester’s neonatal deaths and police investigation, dated 16/05/2017
Publication Date:
14 January 2025
INQ0002449 – Page 1 of Note of call with Nursing & Midwifery Council, dated 18/05/2017
Publication Date:
25 November 2024
INQ0002449 – Note of a call between Alison Kelly and Kristian Garsed regarding the RCPCH Review, dated 18/05/2017.
Publication Date:
17 January 2025
INQ0017393- Document from the Countess of Chester Hospital, titled FAQs for External Stakeholders, dated 18/05/2017.
Publication Date:
17 January 2025
INQ0101921- Email from Alison Kelly regarding information for regulators and stakeholders regarding neonatal services, dated 18/05/2017.
Publication Date:
17 January 2025
INQ0108441- Email chain between Kristian Garsed and colleagues regarding Regulators and Stakeholder brief and External Stakeholder FAQs, dated 18/05/2017.
Publication Date:
17 January 2025
INQ0108445- Briefing from the Countess of Chester Hospital titled information for regulators and stakeholders regarding neonatal serivces, dated 18/05/2017.
Publication Date:
17 January 2025
INQ0002796 – email correspondence between Hayley Cooper, Sue Hodkinson and Alison Kelly, dated 22/05/2017
Publication Date:
21 October 2024
INQ0002796 – email correspondence between Hayley Griffiths (nee Cooper), Alison Kelly and Sue Hodkinson, dated 22/05/2017
Publication Date:
6 November 2024
INQ0012232 – Diagram titled Urgent Care Division – Operational Management Structure – Paediatrics, relating to Countess of Chester Hospital staff, dated 24/05/2017.
Publication Date:
11 September 2024
INQ0108337 – Page 1 of text messages between Letby and Karen Rees, dated 24/05/2017
Publication Date:
21 October 2024
INQ0006749 – Report from MBRRACE-UK titled Perinatal Mortality Surveillance Report (UK Perinatal Deaths for Births from January to December 2015
Publication Date:
7 January 2025
INQ0002797 – Pages 9 – 10 – Note of meeting between Alison Kelly, Letby, Hayley Cooper and Sue Hodkinson, dated 03/06/2017
Publication Date:
26 November 2024
INQ0013028 – SLJ6: Report by Alison Kelly (Director of Nursing & Quality, Countess of Chester Hospital NHS Foundation Trust) titled Neonatal Review & Police Investigation into the increase in Neonatal Mortality at the Countess of Chester Hospital NHS Foundation Trust, dated 05/06/2017.
Publication Date:
8 January 2025
INQ0013195 – Exhibit SLJ7: Minutes from The Local Safeguarding Children’s Board meeting, dated 05/06/2017.
Publication Date:
15 January 2025
INQ0005890 – Email relating to a badger query, dated 06/06/2017
Publication Date:
7 October 2024
INQ0098554 – email correspondence between Hayley Cooper and Claire Jones, relating to an FTSU meeting, dated 06/06/2017
Publication Date:
6 November 2024
INQ0098458 – Page 1 Minutes of Freedom to Speak Up Meeting, dated 06/06/2017
Publication Date:
25 November 2024
INQ0098458 – Page 1 of minutes of Freedom to Speak Up Steering Group meeting, dated 06/06/2017
Publication Date:
3 December 2024
INQ0011614 – Exhibit SD/08 – email correspondence from Alan Moore to all Cheshire Coroners, titled ‘Reportable Deaths’, dated 14/06/2017
Publication Date:
20 January 2025
INQ0002450- Minutes of a meeting between Alison Kelly and Kristian Garsed regarding investigation into Letby, dated 15/06/2017.
Publication Date:
17 January 2025
INQ0006771 – email correspondence relating to clinical risk issues at the Countess of Chester Hospital, dated 16/06/2017
Publication Date:
16 October 2024
INQ0067360 – email correspondence between Letby, Karen Rees, Eirian Powell, Alison Kelly and other colleagues, relating to Letby’s attendance on a Neonatal Life Support course, dated between 29/06/2017 and 03/07/2017
Publication Date:
6 November 2024
INQ0003057 – Pages 23 – 24 of Transcript of Facere Melius interview of Karen Rees, dated 01/07/2017
Publication Date:
21 October 2024
INQ0012991 – Page 3 of Transcript of Facere Melius interview with Karen Rees, dated 01/07/2017
Publication Date:
21 October 2024
INQ0099388 – Page 2 of email from John and Sue Letby to Tony Chambers and Sir Duncan Nichol, titled “Urgent IRO LL”, dated 07/07/2017
Publication Date:
2 December 2024
INQ0014683 – Pages 1 – 2 of email correspondence between NHS Improvement relating to the national peer review programme, dated 14/07/2017
Publication Date:
17 October 2024
INQ0003122 – Pages 1 – 2 of email correspondence from Rachel Hopwood to Sir Duncan Nichol, titled “Announcement of appointment as Children’s champion”, dated 18/07/2017
Publication Date:
3 December 2024
INQ0001982 – Page 11 – 12 of Witness statement of Ravi Jayaram, dated 18/09/2017
Source Date:
18 September 2017
Publication Date:
13 November 2024
INQ0073053 – Pages 1 and 3 of email correspondence titled ‘request for information’ dated between 26/09/2017 and 03/11/2017
Source Date:
26 September 2017
Publication Date:
5 November 2024
INQ0004449 – Page 1 of Minutes of a meeting relating to the appointment of Rachel Hopwood as Children’s Champion, dated 09/10/2017
Source Date:
9 October 2017
Publication Date:
3 December 2024
INQ0002451- Email chain between Alison Kelly and Kristian Garsed, regarding the police investigation of Letby, dated between 09/10/2017 and 13/10/2017.
Source Date:
9 October 2017
Publication Date:
17 January 2025
INQ0004451 – Pages 1 – 2 of Minutes of the Meeting of the Medical Staff Committee at the Countess of Chester Hospital, dated 01/11/2017
Source Date:
1 November 2017
Publication Date:
8 October 2024
INQ0001993 – Page 14 of Witness statement of Dr John Michael Gibbs, (Former Consultant Paediatrician, Countess of Chester Hospital), produced for the criminal re-trial of R v Letby, dated 20/11/2017
Source Date:
20 November 2017
Publication Date:
1 October 2024
INQ0063741 – Page 2 of Agenda for Safeguarding Strategy Board Meeting, dated 30/11/2017
Source Date:
30 November 2017
Publication Date:
29 August 2025
INQ0101327 – email correspondence from David Semple to Tony Chambers, Ian Harvey, Alison Kelly and Lorraine Burnett, enclosing the neonatal action plan, dated 01/12/2017
Source Date:
1 December 2017
Publication Date:
8 January 2025
INQ0004456 – Note of a phone call between Stephen Cross and Mr Letby, dated 19/01/2018.
Source Date:
19 January 2018
Publication Date:
29 January 2025
INQ0013196 – Exhibit SLJ8: Minutes from The Local Safeguarding Children’s Board meeting, dated 22/01/2018.
Source Date:
22 January 2018
Publication Date:
15 January 2025
INQ0108599 – Typed extract from Cheshire Live titled Chester hospital chief not expecting any news over baby deaths inquiry before spring, dated 04/02/2018
Source Date:
4 February 2018
Publication Date:
27 November 2024
INQ0012746 – Page 3 of email correspondence from Stephen Brearey to Professor Modi, Royal College of Paediatric and Child Health, dated 05/02/2018
Source Date:
5 February 2018
Publication Date:
7 November 2024
INQ0012734 – Email chain between Dr Stephen Brearey, Professor Neena Modi, Professor Judith Ellis and others, dated between 05/02/2018 and 09/02/2018
Source Date:
5 February 2018
Publication Date:
12 December 2024
INQ0012774 – Page 1 and 2 of email correspondence regarding the Royal College of Paediatrics and Child Health review and police investigation, dated between 06/02/2018 and 08/02/2018
Source Date:
6 February 2018
Publication Date:
3 October 2024
INQ0001404 – Pages 3 and 7 of Witness statement of Melanie Taylor, Neonatal Nurse, relating to [Child O]. Produced for the criminal trial of R v Letby, dated 12/02/2018
Source Date:
12 February 2018
Publication Date:
10 October 2024
INQ0077575 – Email chain between Karen Rees, Karen Townsend and colleagues, regarding protected payments for Lucy Letby, dated 14/02/2018
Source Date:
14 February 2018
Publication Date:
4 November 2024
INQ0012748 – Page 4 of Chronology from Royal College of Paediatrics and Child Health’s Invited Reviews Programme, dated 14/02/2018
Source Date:
14 February 2018
Publication Date:
7 November 2024
INQ0012748 – Pages 1 and 3 – 4 of Chronology from Royal College of Paediatrics and Child Health titled Invited Reviews Programme, dated 14/02/2018
Source Date:
14 February 2018
Publication Date:
11 November 2024
INQ0000859 – Pages 39 and 334 of Medical Records relating to [Child F], dated 23/02/2018
Source Date:
23 February 2018
Publication Date:
9 October 2024
INQ0000016 – Pages 1 and 5 – 6 of Datix Report from the Countess of Chester Hospital in relation to [Child A], document dated 27/03/2018
Source Date:
27 March 2018
Publication Date:
4 November 2024
INQ0013064 – Pages 1 – 3 of Referral submitted by Alison Kelly to the Local Authority Designated Officer (LADO), dated 27/03/2018
Source Date:
27 March 2018
Publication Date:
25 November 2024
INQ0013064- Populated LADO Referral Form by Alison Kelly, referring Lucy Letby, dated 27/03/2018.
Source Date:
27 March 2018
Publication Date:
8 January 2025
INQ0006681 – Page 1 of Letter from the Paediatric Consultant Group to Sir Duncan Nichol, dated 29/03/2018
Source Date:
29 March 2018
Publication Date:
13 November 2024
INQ0006681 – Letter to Sir Duncan Nichol from Countess of Chester consultants, dated 29/03/2018
Source Date:
29 March 2018
Publication Date:
19 November 2024
INQ0088531 – Pages 1 – 2 of Letter from Ravi Jayaram to Sir Duncan Nichol, dated 29/03/2018
Source Date:
29 March 2018
Publication Date:
2 December 2024
INQ0102361 – Page 76 – email correspondence from Sir Duncan Nichol to Dr Jayaram, titled “Consultant paediatricians’ letter”, dated 04/04/2018
Publication Date:
2 December 2024
INQ0079684 – Referral Form from Cheshire West and Chester, titled Allegations Against An Adult Who Works With Children, dated 11/04/2018
Source Date:
11 April 2018
Publication Date:
29 August 2025
INQ0006682 – Page 1 of email correspondence between paediatric consultants regarding actions to be taken by Sir Duncan Nichol, dated 16/04/2018
Source Date:
16 April 2018
Publication Date:
3 October 2024
INQ0006682 – Page 1 of email correspondence from John Gibbs to consultants, titled “Meeting with Sir Duncan Nichol”, dated 16/04/2018
Source Date:
16 April 2018
Publication Date:
2 December 2024
INQ0003092 – Page 1 of email correspondence between Sir Duncan Nichol, Tony Chambers, Ian Harvey and Stephen Cross, titled “Meeting with consultant paediatricians – 16 April”, dated 17/04/2018
Source Date:
17 April 2018
Publication Date:
2 December 2024
INQ0004474 – Page 1 of email correspondence between Sir Duncan Nichol, Tony Chambers, Ian Harvey and Stephen Cross, titled “Meeting with consultant paediatricians – 16 April”, dated 17/04/2018
Source Date:
17 April 2018
Publication Date:
2 December 2024
INQ0102361 – Pages 78 – 81 – Letter from paediatricians for response by Tony Chambers, dated 30/04/2018
Source Date:
30 April 2018
Publication Date:
2 December 2024
INQ0102361 – Page 83 – email correspondence from Sir Duncan Nichol to Tony Chambers, Ian Harvey and Stephen Cross titled “Response to the consultant paediatricians, dated 24/05/2018
Publication Date:
2 December 2024
INQ0006750 – Report from MBRRACE-UK titled Perinatal Mortality Surveillance Report (UK Preinatal Deaths for births from January to December 2016), dated June 2018
Publication Date:
7 January 2025
INQ0013040- Minutes from Countess of Chester Incident Coordination Call, regarding response to media surrounding incident investigation, dated 04/06/2018.
Publication Date:
10 January 2025
INQ0003194 – Minutes of a ‘Countess of Chester Incident Coordination Call’, dated 04/06/2018
Publication Date:
16 January 2025
INQ0004485 – Pages 1 and 3 of Minutes of a meeting of the Medical Staff Committee at the Countess of Chester Hospital, dated 07/06/2018
Publication Date:
8 October 2024
INQ0101308 – Emails between Dr Bill Yoxall and Dr Stephen Brearey, regarding Police statement check, dated between 25/06/2018 and 26/06/2018
Publication Date:
16 January 2025
INQ0101113 – Email relating to the Royal College of Paediatrics and Child Health review, dated 04/07/2018
Publication Date:
3 October 2024
INQ0012733 – Emails between Dr Stephen Brearey, Professor Russell Viner and colleagues, dated between 04/07/2018 and 10/07/2018
Publication Date:
12 December 2024
INQ0017758 – Exhibit SLJ9: Minutes of the Cheshire West and Chester Local Safeguarding Board meeting, dated 04/07/2018.
Publication Date:
15 January 2025
INQ0006212- Email from Kristian Garsed to Paul Hughes regarding an update on the arrest of Letby, dated 04/07/2018.
Publication Date:
17 January 2025
INQ0002455 - Email regarding the referral of Lucy Letby to the NMC, dated 05/07/2018.
Publication Date:
10 September 2025
INQ0000056 - Page 4 of Witness Statement of Dr David Harkness, dated 05/07/2018.
Publication Date:
12 September 2025
INQ0002938 - Emails regarding the NMC's advice following the allegations made against Lucy Letby, dated 06/07/2016.
Publication Date:
10 September 2025
INQ0013038- Minutes from Countess of Chester Incident Coordination Panel Meeting, regarding arrest of Lucy Letby, dated 10/07/2018.
Publication Date:
10 January 2025
INQ0011611 – Exhibit SD/05 – Minutes from a Crime Operations Meeting on 11 July 2018, addressing senior police managers, dated 11/07/2018
Publication Date:
20 January 2025
INQ0083556 – Pages 1 – 3 of email correspondence between Dr Jameson and Cheshire Police, dated 16/07/2018
Publication Date:
8 October 2024
INQ0013197 – Exhibit SLJ10: Minutes from The Local Safeguarding Children’s Board meeting , dated 27/07/2018.
Publication Date:
15 January 2025
INQ0017911 – Page 7 of Witness statement of Kathryn De Beger, dated 07/08/2018
Source Date:
7 August 2018
Publication Date:
9 October 2024
INQ0103159 – Page 1 of Email chain between Dr Stephen Brearey and colleagues, regarding the invited review, dated 20/08/2018
Source Date:
20 August 2018
Publication Date:
19 November 2024
INQ0099064 – Page 18 of Exhibit SG/3: message from Ian Harvey to Susan Gilby, dated 29/08/2018.
Source Date:
29 August 2018
Publication Date:
25 February 2025
INQ0098147 – Pages 1 – 2, 4 – 5 and 6 – 8 of Minutes of Extraordinary Medical Staff Meeting, dated 19/09/2018
Source Date:
19 September 2018
Publication Date:
8 October 2024
INQ0098147 – Pages 1 – 7 of minutes of Extra-ordinary Medical Staff Committee meeting, dated 19/09/2018
Source Date:
19 September 2018
Publication Date:
2 December 2024
INQ0017183 – Email from Lyn Simpson to Richard Barker (NHS England) regarding a job role for Tony Chambers, dated 25/09/2018
Source Date:
25 September 2018
Publication Date:
21 November 2024
INQ0012637 – Pages 20, 97, 133 – 134 and 138 of Report from Tom Kark KC and Jane Russell titled A review of the Fit and Proper Person Test, dated November 2018
Source Date:
1 November 2018
Publication Date:
17 January 2025
INQ0000526 – Pages 10 – 12 of Witness Statement of Matthew Neame, dated 08/11/2018
Source Date:
8 November 2018
Publication Date:
2 October 2024
INQ0001542 – Pages 2-3 of Witness Statement of Mother Q in relation to the criminal investigation, dated 08/11/2018
Source Date:
8 November 2018
Publication Date:
9 September 2025
INQ0099064 – Pages 4 – 7 of Exhibit SG/3: emails between Susan Gilby, Duncan Nichol and Stephen Cross titled ‘Governance Overview November 2018’ and attached Governance Framework Overview, dated 13/11/2018 and 14/11/2018.
Source Date:
13 November 2018
Publication Date:
25 February 2025
INQ0086797 – Pages 13, 14 and 21 of Bundle of documents presented for meeting of the Learning from Deaths Group at the Countess of Chester Hospital dated 16/11/2018, including the ‘Mortality Review’ policy and the Mortality Surveillance Group Terms of Reference.
Source Date:
16 November 2018
Publication Date:
25 February 2025
INQ0000643 - Pages 2 - 3 of Witness Statement of Doctor S, dated 23/11/2018.
Source Date:
23 November 2018
Publication Date:
12 September 2025
INQ0016484 – Page 3 of Policy from Guy’s and St Thomas’ NHS Foundation Trust titled Capability Policy and Procedure for Medical and Dental Staff, dated December 2018
Source Date:
1 December 2018
Publication Date:
13 December 2024
INQ0012911 – Pages 1, 19 and 30 of Intercollegiate Document from Royal College of Nursing, titled “Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff – Fourth edition”, dated January 2019
Source Date:
1 January 2019
Publication Date:
17 January 2025
INQ0001986 - Pages 4 - 6 of Witness Statement of Dr Ravi Jayaram, dated 10/01/2019.
Source Date:
10 January 2019
Publication Date:
12 September 2025
INQ0007203 – Page 9 of Witness Statement of Dr Stephen Brearey for General Medical Council v Mr Ian Harvey, dated 17/01/2019
Source Date:
17 January 2019
Publication Date:
29 August 2025
INQ0006890 – Page 289 of Witness statement of Dr Brearey, dated 17/01/2019
Source Date:
17 January 2019
Publication Date:
27 November 2024
INQ0015683 – Page 31 of Settlement Agreement/Deed of Settlement between the Countess of Chester NHS Foundation and Tony Chambers, dated 28/01/2019
Source Date:
28 January 2019
Publication Date:
27 November 2024
INQ0001996 – Pages 3 – 4 of Witness Statement of Sian Williams, dated 07/02/2019
Source Date:
7 February 2019
Publication Date:
5 November 2024
INQ0013199 – Exhibit SLJ11: Minutes from The Local Safeguarding Children’s Board meeting, dated 11/02/2019.
Source Date:
11 February 2019
Publication Date:
15 January 2025
INQ0001923 – Page 5 of Witness Statement of Alison Kelly in relation to the criminal investigation, dated 15/02/2019
Source Date:
15 February 2019
Publication Date:
29 August 2025
INQ0001333 – Table titled Chronology of Events, in relation to [Child O], [Child P] & [Child R], 08/03/2019
Publication Date:
29 August 2025
INQ0107001 – Pages 1, 3, 5, 6, 8 and 14 of Report from the NHS titled Managing Safeguarding Allegations Against Staff: Policy and Procedure, regarding procedures for staff members behaving in a way unsuited to work with a child, young person or adult at risk, dated 25/03/2019
Source Date:
25 March 2019
Publication Date:
17 January 2025
INQ0013042- Minutes from the Incident Coordination Panel Meeting, regarding ongoing criminal investigation, dated 05/04/2019
Publication Date:
10 January 2025
INQ0001985 – Pages 14 – 15 of Witness statement of Dr Michael Mcguigan, dated 16/05/2019
Publication Date:
9 January 2025
INQ0014183 – Pages 1, 2 – 3 and 5 – 6 of Report from the Care Quality Commission titled Inspection Report, Countess of Chester Hospital NHS Foundation Trust, dated 17/05/2019.
Publication Date:
25 February 2025
INQ0000536 – Pages 1 and 7 of Witness Statement of Dr Rachel Elizabeth Chang, dated 20/05/2019
Publication Date:
2 October 2024
INQ0014610 – Letter from Dr Brearey to Susan Gilby, regarding missing emails from 2016, dated 24/05/2019.
Publication Date:
25 February 2025
INQ0000531 – Pages 1 – 2 of Witness Statement of Yvonne Griffiths, dated 11/06/2019
Publication Date:
16 October 2024
INQ0007482 – Pages 68 – 69 and 92 of Transcript of police interview with Eirian Powell, dated 11/06/2019
Publication Date:
17 October 2024
INQ0012742 – Note of meeting between Susie Holt and Stephen Brearey with Jo Revill and Emily Arkell regarding police investigation and reflections, dated 12/07/2019
Publication Date:
12 December 2024
INQ0010447 – Pages 1 – 2 of Article titled Patient safety regulation in the NHS: mapping the regulatory landscape of healthcare, authored by Eirini Oikonomou, Jane Carthey, Carl Macrae and Charles Vincent, dated 13/07/2019
Publication Date:
17 January 2025
INQ0013187 – Exhibit SLJ12: Minutes from Cheshire West and Chester Safeguarding Children Partnership Executive meeting, dated 17/07/2019.
Publication Date:
15 January 2025
INQ0014568 – Page 11 and 33 of Transcript of police interview with Chris Green, dated 02/10/2019
Source Date:
2 October 2019
Publication Date:
6 November 2024
INQ0017846 – Pages 12 – 16 and 28 – 29 of transcript of police witness interview of Annette Weatherley, dated 20/01/2020
Source Date:
20 January 2020
Publication Date:
7 November 2024
INQ0007707 – Page 20 of transcript of police interview with Yvonne Griffiths, relating to [Child C], dated 30/04/2020
Source Date:
30 April 2020
Publication Date:
16 October 2024
INQ0012986 – Pages 1 and 10 – 11 of Facere Melius interview with Yvonne Griffiths, dated 30/06/2020
Publication Date:
16 October 2024
INQ0003527 – Pages 1 – 2 of email correspondence between Claire Raggett and Eirian Powell regarding the independent review meeting, dated 30/06/2020
Publication Date:
17 October 2024
INQ0012995 – Pages 1 – 2 of Transcript of interview with Dr Jameson, conducted by Facere Melius, dated 08/07/2020
Publication Date:
8 October 2024
INQ0012993 – Pages 1 and 8 of Transcript of interview with Julie Fogarty (Head of Midwifery, Countess of Chester Hospital) conducted by Facere Melius, dated 14/07/2020
Publication Date:
16 October 2024
INQ0003058 – Pages 12 – 13 and 15 of Transcript of an interview between Facere Melius and Andrew Higgins, dated 15/07/2020
Publication Date:
3 December 2024
INQ0012998 – Pages 5 and 11 of Transcript of Facere Melius interview with Simon Holden, dated 15/07/2020
Publication Date:
3 December 2024
INQ0106970 – Pages 1-64 – Witness Statement of Andrew Bibby, dated 16/07/20204
Publication Date:
17 January 2025
INQ0107706 – Pages 140-142 – Handwritten notes of Stephen Cross, of a meeting on 20 July 2016.
Publication Date:
17 January 2025
INQ0107706 – Page 143 – Handwritten notes of Stephen Cross of a meeting on 27 July 2016
Publication Date:
17 January 2025
INQ0107810 – Page 7 of Code of Conduct for NHS Managers, dated October 2002
Source Date:
1 October 2020
Publication Date:
15 January 2025
INQ0107706 – Pages 1-45 – Facere Melius Interview between Stephen Cross and Darren Thorne, dated 01/12/2020.
Source Date:
1 December 2020
Publication Date:
17 January 2025
INQ0012175 – Pages 9, 25 and 43 – 44 of Transcript of police interview with Sue Hodkinson, dated 28/01/2021.
Source Date:
28 January 2021
Publication Date:
26 November 2024
INQ0009255 – Pages 1, 3 and 6 of Report from NHS England titled NHS Patient Safety Strategy: 2021 Update, dated February 2021
Source Date:
1 February 2021
Publication Date:
17 January 2025
INQ0010176 - Report titled External Review of the RCPCH Invited Reviews Service, dated March 2021
Publication Date:
15 September 2025
INQ0001252 - Page 2 of Witness Statement of Sarah Davies re [Child L], dated 04/11/2021.
Source Date:
4 November 2021
Publication Date:
12 September 2025
INQ0012363 – Pages 1 and 4 of Report from The Royal College of Pathologists titled National Medical Examiner’s Good Practice Series No. 6, Medical examiners and child deaths, dated March 2022
Publication Date:
14 January 2025
INQ0002377 – Page 1 of Report titled Leadership for a collaborative and inclusive future, published 8 June 2022
Publication Date:
8 January 2025
INQ0014184 – Pages 1, 3 – 4, 8 and 10 of Report from the Care Quality Commission titled Inspection Report, Countess of Chester Hospital NHS Foundation Trust, dated 15/06/2022.
Publication Date:
25 February 2025
INQ0108675 – Pages 1, 5, 7, 18 – 19, 27 and 33 of Guidance from the National Bereavement Care Pathway for Pregnancy and Baby Loss titled Neonatal Death, dated July 2022
Publication Date:
14 January 2025
INQ0009265 – Pages 1, 3, 5, 7, 9 and 11 of Report from NHS England titled Patient Safety Incident Response Framework, dated August 2022.
Source Date:
1 August 2022
Publication Date:
17 January 2025
INQ0014166 – Pages 1, 3 – 37 and 49 of Policy from the Countess of Chester Hospital titled Safeguarding and Promoting the Welfare of Children, dated 01/09/2022
Source Date:
1 September 2022
Publication Date:
13 January 2025
INQ0010268 - Page 41 of Transcript of Day 14 of the criminal trial of R v Letby, Dr Ravi Jayaram re [Child A], dated 24/10/2022.
Source Date:
24 October 2022
Publication Date:
12 September 2025
INQ0010269 – Page 5 of transcript of the trial of R v Lucy Letby (day 15), evidence of Doctor V and others relating to [Child A] & [Child B], dated 25/10/2022
Source Date:
25 October 2022
Publication Date:
7 October 2024
INQ0014511 – Pages 1, 4 – 5 and 13 – 15 of Guidance by NHS titled, “NHS Complaint Standards, Summary of expectations”, dated 01/12/2022
Source Date:
1 December 2022
Publication Date:
10 December 2024
INQ0012813 – Guidance from Royal College of Paediatrics and Child Health titled Escalation Process and Guidance, Management of concerns identified during invited review (Version 2.0), dated 01/03/2023
Publication Date:
11 November 2024
INQ0101997 – Pages 1, 63 and 68 of Sudden Unexpected Deaths in Infants and Children (SUDIC) Guidelines for Cheshire East, Cheshire West & Chester, Halton and Warrington, April 2023
Publication Date:
12 November 2024
INQ0014160 – Pages 1, 8, 100 – 102, 123, 130, 133 – 138 and 148 -150 of Guidelines from the Countess of Chester Hospital titled Pan-Cheshire Sudden Unexpected Deaths in Infants and Children Proforma and Guidance, dated 01/04/2023
Publication Date:
13 January 2025
INQ0012295 – Pages 1 – 2 of Webpage from Royal College of Paediatrics and Child Health titled Record High: Over 400,000 children waiting for treatment amidst child health crisis regarding child health crisis, dated 11/05/2023
Publication Date:
13 December 2024
INQ0001582 – Page 2 of Witness Statement of Mother Q in relation to the criminal investigation, dated 23/06/2023
Publication Date:
9 September 2025
INQ0014545 – Pages 1, 7 – 10, 26 – 27, 31, 34 – 35 and 39 – 40 of Report from the Parliamentary and Health Service Ombudsman titled “Broken trust: making patient safety more than just a promise”, dated 29/06/2023
Publication Date:
10 December 2024
INQ0108389 – Handwritten notes by Kirstin Hannaford, relating to the escalation of concerns at the Countess of Chester Hospital and inspections by the CQC, 06-07/07/2023
Publication Date:
10 January 2025
INQ0017319 – Pages 1 and 2 of Notes taken from call with Julie Hughes regarding Care Quality Commission inspection of the Countess of Chester Hospital dated 07/07/2023
Publication Date:
15 November 2024
INQ0012645 – Pages 1, 4, 36 and 37 of Report from NHS England titled NHS England Fit and Proper Person Test Framework for board members, dated 02/08/2023
Source Date:
2 August 2023
Publication Date:
17 January 2025
INQ0104624 – Pages 1, 2 and 3 of Document from the Care Quality Commission titled “Countess of Chester Hospital NHS Foundation Trust – Lucy Letby trial, Internal briefing document” dated 16/08/2023
Source Date:
16 August 2023
Publication Date:
15 November 2024
INQ0108001 - Letter from Doctor ZA to parents of [Child E] & [Child F], dated 11/10/2023.
Source Date:
11 October 2023
Publication Date:
12 September 2025
INQ0012274 – Pages 1, 7, 26 – 27 and 32 of Publication from Cambridge University Press titled Governance and Leadership, dated November 2023
Source Date:
1 November 2023
Publication Date:
13 December 2024
INQ0014161 – Pages 1, 5 and 30 – 31 of Guidelines in the Event of a Child Death, dated 29/11/2023
Source Date:
29 November 2023
Publication Date:
13 January 2025
INQ0006759 – Witness Statement of Professor Neena Modi, lead at the UK National Neonatal Research Database (NNRD), dated 05/12/2023
Source Date:
5 December 2023
Publication Date:
28 January 2025
INQ0006757 – Witness statement of Professor Marian Knight OBE, dated 20/12/2023
Source Date:
20 December 2023
Publication Date:
7 January 2025
INQ0008966 – Witness Statement of Professor Sir David Spiegelhalter, dated 08/01/2024
Source Date:
8 January 2024
Publication Date:
15 January 2025
INQ0008975 – Witness statement of Christine Hurst, dated 15/01/2024
Source Date:
15 January 2024
Publication Date:
20 January 2025
INQ0012282 – Pages 1 – 2 of Online article from British Association of Perinatal Medicine titled Evaluating culture in your unit or network, dated 25/01/2024
Source Date:
25 January 2024
Publication Date:
13 December 2024
INQ0014581 – First Witness Statement of Mike Leaf, dated 26/01/2024
Source Date:
26 January 2024
Publication Date:
13 January 2025
INQ0011616 – Witness Statement of Stephanie Davies, dated 30/01/2024
Source Date:
30 January 2024
Publication Date:
20 January 2025
INQ0010439 -Witness Statement provided by Professor Richard Feltbower, Professor Elizabeth Draper and Dr Sarah Seaton, on behalf of The Paediatric Intensive Care Audit Network, dated 30/01/2024
Source Date:
30 January 2024
Publication Date:
28 January 2025
INQ0002412 – Witness statement of Andrea Sutcliffe, dated 02/02/2024
Source Date:
2 February 2024
Publication Date:
9 January 2025
INQ0012335 – Witness Statement of Dr Rosie Benneyworth, dated 05/02/2024
Source Date:
5 February 2024
Publication Date:
8 January 2025
INQ0108890 – Second witness statement of Duncan Burton (Deputy Chief Nursing Officer for England, National Health Service), on behalf of NHS England, dated 06/02/2024.
Source Date:
6 February 2024
Publication Date:
21 March 2025
INQ0011975 – Witness Statement of Louise Ansari, on behalf of Healthwatch England, dated 07/02/2024
Source Date:
7 February 2024
Publication Date:
23 January 2025
INQ0017463 – Witness statement of Robert Okunnu, dated 08/02/2024
Source Date:
8 February 2024
Publication Date:
17 December 2024
INQ0012634 – Witness Statement of Ian Trenholm, Chief Executive of the Care Quality Commission, dated 12/02/2024.
Source Date:
12 February 2024
Publication Date:
14 January 2025
INQ0012649 – Witness Statement of Graham Peter Urwin, on behalf of NHS Cheshire and Merseyside Integrated Care Board, dated 14/02/2024
Source Date:
14 February 2024
Publication Date:
23 January 2025
INQ0012963 – Witness Statement of Louise Barry, on behalf of Healthwatch Cheshire, dated 14/02/2024
Source Date:
14 February 2024
Publication Date:
23 January 2025
INQ0017472 – Witness Statement of Michelle Turner, on behalf of Liverpool Women’s Hospital NHS Foundation Trust, dated 15/02/2024
Source Date:
15 February 2024
Publication Date:
29 January 2025
INQ0012962 – Witness Statement provided by Dr Eleri Adams, on behalf of The British Association of Perinatal Medicine, dated 16/02/2024
Source Date:
16 February 2024
Publication Date:
24 January 2025
INQ0101114 – Witness Statement of Professor Joe McDonald, dated 16/02/2024
Source Date:
16 February 2024
Publication Date:
29 January 2025
INQ0014065 – Page 1 of Weekly Hospital Bulletin dated 19/02/2024
Source Date:
19 February 2024
Publication Date:
13 January 2025
INQ0013290 – Witness Statement of Stuart Lythgoe on behalf of the Hospital Consultants and Specialists Association, dated 21/02/2024
Source Date:
21 February 2024
Publication Date:
17 January 2025
INQ0013010 – Witness Statement of Professor Philip Banfield, on behalf of the British Medical Association, dated 21/02/2024
Source Date:
21 February 2024
Publication Date:
23 January 2025
INQ0017274 – Witness statement of Dame Linda Pollard, dated 21/02/2024
Source Date:
21 February 2024
Publication Date:
24 January 2025
INQ0017181 – Witness Statement of Harry Cayton, dated 22/02/2024.
Source Date:
22 February 2024
Publication Date:
24 January 2025
INQ0017157 – Witness Statement provided by Professor Karen Luyt on behalf of the National Child Mortality Database, dated 22/02/2024
Source Date:
22 February 2024
Publication Date:
28 January 2025
INQ0013307 -Witness Statement of Professor Jonathan Benger CBE, on behalf of NICE, dated 26/02/2024
Source Date:
26 February 2024
Publication Date:
28 January 2025
INQ0014062 – Rule 9 questionnaire response of Santasha Culshaw, dated 26/02/2024.
Source Date:
26 February 2024
Publication Date:
20 February 2025
INQ0108668 – Pages 2 – 3 of Publication from NHS England titled NHS Leadership competency framework for board members, dated 28/02/2024
Source Date:
28 February 2024
Publication Date:
7 January 2025
INQ0108668 – Pages 1, 3, 5 and 10 of Publication from NHS England titled NHS Leadership competency framework for board members, dated 28/02/2024
Source Date:
28 February 2024
Publication Date:
17 January 2025
INQ0017757 – Witness Statement of Helen Vernon, on behalf of NHS Resolution, dated 29/02/2024
Source Date:
29 February 2024
Publication Date:
23 January 2025
INQ0014549 – Witness Statement of Charles Hamilton Massey, on behalf of the General Medical Council, dated 04/03/2024
Publication Date:
20 January 2025
INQ0017994 – Witness statement of Sybille Raphael, on behalf of Protect, dated 04/03/2024
Publication Date:
28 January 2025
INQ0017905 – Witness statement of Sir Andrew Morris, dated 05/03/2024
Publication Date:
20 January 2025
INQ0018075 – Witness Statement of Nick Hulme, dated 06/03/2024
Publication Date:
24 January 2025
INQ0101381 – Witness Statement of Ken Jarrold CBE, dated 06/03/2024
Publication Date:
24 January 2025
INQ0014572 – Witness statement of Dr Eleri Adams, dated 07/03/2024
Publication Date:
20 January 2025
INQ0017494 – Witness statement of Robert Okunnu, dated 08/03/2024
Publication Date:
17 December 2024
INQ0018029 – Page 14 of Document from NHS England Specialised Commissioning titled Schedule 2, the services, service specifications, Neonatal Critical Care, regarding categories of neonatal critical care and the neonatal unit, dated 11/03/2024
Source Date:
11 March 2024
Publication Date:
7 January 2025
INQ0014595 – Rule 9 questionnaire response of Stephanie Blenkhorn (nee Terry), dated 11/03/2024.
Source Date:
11 March 2024
Publication Date:
20 February 2025
INQ0014599 – Pages 5 – 6 of Witness statement of Sir Robert Behrens, dated 13/03/2024
Source Date:
13 March 2024
Publication Date:
10 December 2024
INQ0014599 – Witness statement of Rob Behrens, dated 13/03/2024.
Source Date:
13 March 2024
Publication Date:
15 January 2025
INQ0014596 – Rule 9 questionnaire response of Susan Needham, dated 13/03/2024.
Source Date:
13 March 2024
Publication Date:
20 February 2025
INQ0014570 – Witness statement of Dr Alan Fletcher, dated 14/03/2024
Source Date:
14 March 2024
Publication Date:
17 December 2024
INQ0014592 – Rule 9 questionnaire response of Deborah Moore, dated 15/03/2024.
Source Date:
15 March 2024
Publication Date:
17 February 2025
INQ0017975 – Witness statement of Dr Joanna Garstang [dated 20/03/2024]
Source Date:
20 March 2024
Publication Date:
26 September 2024
INQ0015456 – Rule 9 questionnaire response of Cherryl Cuthbertson-Taylor, dated 20/03/2024.
Source Date:
20 March 2024
Publication Date:
17 February 2025
INQ0015460 – Witness Statement of Susan Morton (nee Brookes), dated 20/03/2024.
Source Date:
20 March 2024
Publication Date:
20 February 2025
INQ0015453 – Witness statement of Patricia Marquis, dated 21/03/2024.
Source Date:
21 March 2024
Publication Date:
15 January 2025
INQ0014552 – Second Witness Statement of Professor Sir Stephen Powis on behalf of NHS England, dated 21/03/2024
Source Date:
21 March 2024
Publication Date:
17 January 2025
INQ0017163 – Rule 9 questionnaire response of Vicky Blamire, dated 24/03/2024.
Source Date:
24 March 2024
Publication Date:
20 February 2025
INQ0017493 – Witness statement of Dr Camilla Kingdon, dated 25/03/2024
Source Date:
25 March 2024
Publication Date:
17 December 2024
INQ0017495 – Witness statement of Professor Sir Stephen Powis, on behalf of NHS England, dated 25/03/2024
Source Date:
25 March 2024
Publication Date:
17 January 2025
INQ0017161 – Witness Statement of Lisa Walker, dated 25/03/2024
Source Date:
25 March 2024
Publication Date:
17 February 2025
INQ0017162 – Witness Statement of Paula Baden, dated 26/03/2024.
Source Date:
26 March 2024
Publication Date:
17 February 2025
INQ0017158 – Witness statement 1 of Jane Tomkinson [dated 27/03/2024]
Source Date:
27 March 2024
Publication Date:
13 January 2025
INQ0017159 – Witness statement 2 of Jane Tomkinson [dated 27/03/2024]
Source Date:
27 March 2024
Publication Date:
13 January 2025
INQ0017160 – Witness statement 3 of Jane Tomkinson [dated 27/03/2024]
Source Date:
27 March 2024
Publication Date:
13 January 2025
INQ0017276 – Witness Statement to the Thirlwall Inquiry of General Sir Gordon Messenger, dated 28/03/2024
Source Date:
28 March 2024
Publication Date:
8 January 2025
INQ0017450 – Witness Statement of David Evans, dated 29/03/2024
Source Date:
29 March 2024
Publication Date:
24 January 2025
INQ0017277 – Rule 9 questionnaire response of Pauline Fong, dated 29/03/2024.
Source Date:
29 March 2024
Publication Date:
17 February 2025
INQ0017280 – Witness Statement of Valerie Thomas, dated 31/03/2024.
Source Date:
31 March 2024
Publication Date:
20 February 2025
INQ0018076 – Report from Nuffield Trust for the Thirlwall Inquiry titled Analysis of questionnaires from 120 NHS Trusts, dated April 2024
Publication Date:
13 January 2025
INQ0017279 – Witness Statement of Shelley Tomlins, dated 01/04/2024.
Publication Date:
20 February 2025
INQ0017809 – Second Witness Statement of Ian Trenholm, on behalf of the Care Quality Commission, dated 04/04/2024
Publication Date:
20 January 2025
INQ0017976 – Witness statement of Alan Clamp, dated 05/04/2024.
Publication Date:
15 January 2025
INQ0015468 – Witness statement of William Vineall, on behalf of the Department of Health and Social Care, dated 05/04/2024
Publication Date:
16 January 2025
INQ0101315 – Witness statement of Robert Okunnu, dated 07/04/2024
Publication Date:
17 December 2024
INQ0017489 – Witness Statement of Laura Eagles, dated 07/04/2024.
Publication Date:
17 February 2025
INQ0017487 – Witness Statement of Dr Sarah Rylance, dated 08/04/2024.
Publication Date:
4 March 2025
INQ0018072 – Witness Statement of Julie Coope, dated 09/04/2024
Publication Date:
24 January 2025
INQ0017488 – Rule 9 questionnaire response of Janet Cox, dated 09/04/2024.
Publication Date:
20 February 2025
INQ0017804- Page 4 of Guidance from Nursing and Midwife Council titled Decision making factors for interim orders, dated 10/04/2024
Source Date:
10 April 2024
Publication Date:
8 January 2025
INQ0100828 – Witness statement of Professor Sir Stephen Powis, dated 10/04/2024
Source Date:
10 April 2024
Publication Date:
17 January 2025
INQ0017825 – Witness Statement of Amy Davies, dated 10/04/2024.
Source Date:
10 April 2024
Publication Date:
17 February 2025
INQ0017827 – Witness Statement of Nurse X, dated 10/04/2024.
Source Date:
10 April 2024
Publication Date:
17 February 2025
INQ0017906 – Witness Statement of Helene Donnelly, dated 11/04/2024
Source Date:
11 April 2024
Publication Date:
24 January 2025
INQ0017826 – Witness Statement of Caroline Bennion, dated 11/04/2024.
Source Date:
11 April 2024
Publication Date:
17 February 2025
INQ0017829 – Witness Statement of Sophia Ellis, dated 11/04/2024.
Source Date:
11 April 2024
Publication Date:
20 February 2025
INQ0017842 - Page 30, 32 of Witness Statement of Nicholas Rheinberg, dated 11/04/2024.
Source Date:
11 April 2024
Publication Date:
10 September 2025
INQ0017836 – Witness Statement to the Thirlwall Inquiry of Tom Luce, dated 12/04/2024
Source Date:
12 April 2024
Publication Date:
28 January 2025
INQ0017972 – Witness Statement of Daniel Logan Grant, on behal of the National Association of Designated Safeguarding Leads, dated 14/04/2024
Source Date:
14 April 2024
Publication Date:
28 January 2025
INQ0017822- Witness Statement of Helen Brackenbury, dated 15/04/2024.
Source Date:
15 April 2024
Publication Date:
8 January 2025
INQ0017823- Witness Statement of Paul Jenkins, dated 15/04/2024.
Source Date:
15 April 2024
Publication Date:
8 January 2025
INQ0017821 – Witness Statement of Emma Kate Taylor, dated 15/04/2024.
Source Date:
15 April 2024
Publication Date:
10 January 2025
INQ0017833 – Witness Statement of Thomas A. C. Bell, dated 15/04/2024
Source Date:
15 April 2024
Publication Date:
24 January 2025
INQ0017824 – Witness Statement of Sian Jones, dated 16/04/2024.
Source Date:
16 April 2024
Publication Date:
15 January 2025
INQ0018067 – Witness Statement of Dr Andrew Brunton, dated 16/04/2024.
Source Date:
16 April 2024
Publication Date:
17 February 2025
INQ0017837 – Witness Statement of Samantha O’Brien, dated 16/04/2024.
Source Date:
16 April 2024
Publication Date:
20 February 2025
INQ0101406 – Witness Statement of Dr Jennifer Dixon DBE, dated 17/04/2024
Source Date:
17 April 2024
Publication Date:
24 January 2025
INQ0018000 – Rule 9 questionnaire response of Susanne Boggan, dated 17/04/2024.
Source Date:
17 April 2024
Publication Date:
20 February 2025
INQ0017996 – Witness Statement of Dr Katherine Lyddon, dated 19/04/2024.
Source Date:
19 April 2024
Publication Date:
4 March 2025
INQ0017995 – Witness Statement of Dr Emily Thomas, dated 22/04/2024.
Source Date:
22 April 2024
Publication Date:
4 March 2025
INQ0018005 – Witness statement of Sir Terence Stephenson, dated 24/04/2024
Source Date:
24 April 2024
Publication Date:
24 January 2025
INQ0017998 – Rule 9 questionnaire response of Jennifer Jones-Key, dated 24/04/2024.
Source Date:
24 April 2024
Publication Date:
17 February 2025
INQ0018064 – Witness Statement of Alisa Simpson, dated 24/04/2024.
Source Date:
24 April 2024
Publication Date:
17 February 2025
INQ0018001 – Witness Statement of Dr Katherine Davies (nee Brown), dated 25/04/2024.
Source Date:
25 April 2024
Publication Date:
4 March 2025
INQ0018081 – Witness Statement of Louise Weaver-Lowe, dated 26/04/2024
Source Date:
26 April 2024
Publication Date:
20 January 2025
INQ0018080 – Witness Statement of Duncan Burton, dated 26/04/2024
Source Date:
26 April 2024
Publication Date:
23 January 2025
INQ0018066 – Witness Statement of Alison Ventress, dated 26/04/2024.
Source Date:
26 April 2024
Publication Date:
17 February 2025
INQ0018065 – Witness Statement of Bernadette Butterworth, dated 29/04/2024.
Source Date:
29 April 2024
Publication Date:
17 February 2025
INQ0101334 – Witness Statement of Caroline Oakley, dated 30/04/2024.
Source Date:
30 April 2024
Publication Date:
17 February 2025
INQ0018069 – Witness Statement of Dr Katarzyna Cooke, dated 30/04/2024.
Source Date:
30 April 2024
Publication Date:
4 March 2025
INQ0018070 – Witness Statement of Dr Rachel Chang, dated 30/04/2024.
Source Date:
30 April 2024
Publication Date:
4 March 2025
INQ0098717 – Report from Picker titled The Thirlwall Inquiry Neonatal Staff Survey, dated May 2024
Publication Date:
13 January 2025
INQ0108722 – Pages 1 – 5 of Guidance from NHS Employers titled The use of settlement agreements and confidentiality clauses, dated May 2024
Publication Date:
13 January 2025
INQ0018077 – Witness Statement of Dame Ruth May, dated 01/05/2024
Publication Date:
20 January 2025
INQ0018068 – Witness Statement of Doctor S, dated 01/05/2024.
Publication Date:
17 February 2025
INQ0098108 – Witness Statement of Dr Peter Fielding, dated 02/05/2024.
Publication Date:
4 March 2025
INQ0098046 – Third Witness Statement provided by Andrea Sutcliffe on behalf of The Nursing and Midwifery Council, dated 07/05/2024.
Publication Date:
29 January 2025
INQ0098106 – First Disclosure Statement on behalf of the Countess of Chester Hospital made by Claire Elizabeth Raggett, dated 08/05/2024
Publication Date:
13 January 2025
INQ0102755 – Witness statement of Dr Bill Kirkup CBE, dated 08/05/2024
Publication Date:
24 January 2025
INQ0098316 – Witness Statement of Dr Christopher Wood, dated 10/05/2024.
Publication Date:
17 February 2025
INQ0098320 – Witness Statement of Sarah Louise Davies, dated 15/05/2024
Publication Date:
14 January 2025
INQ0102061 – Witness Statement of David Wyndham Alexander Milligan, dated 16/05/2024
Publication Date:
10 January 2025
INQ0098315 – Witness Statement of Christopher Booth, dated 16/05/2024.
Publication Date:
17 February 2025
INQ0100826 – Rule 9 questionnaire response of Nicola Dennison, dated 21/05/2024.
Publication Date:
17 February 2025
INQ0101347 – Witness Statement of Graham Stewart, dated 22/05/2024
Publication Date:
10 January 2025
INQ0099075 – Page 12 of Witness Statement of Nurse ZC, dated 23/05/2024
Publication Date:
2 October 2024
INQ0099074 – Witness Statement of Dr Gail Beech, dated 24/05/2024.
Publication Date:
4 March 2025
INQ0099066 - Pages 12 - 13 of Witness Statement of Shirley Bowles, dated 24/05/2024.
Publication Date:
12 September 2025
INQ0101089 – Witness statement of Dr Jessica Burke, dated 28/05/2024.
Publication Date:
25 March 2025
INQ0100894 – Witness statement of Tracy Bullock, dated 29/05/2024
Publication Date:
9 January 2025
INQ0101071 – Witness statement of Karen Milne, dated 29/05/2024
Publication Date:
10 January 2025
INQ0101068 – Rule 9 questionnaire response of Clare Bevan, dated 29/05/2024.
Publication Date:
17 February 2025
INQ0101069 – Rule 9 questionnaire response of Faith Chidongo, dated 29/05/2024.
Publication Date:
17 February 2025
INQ0101328 – Rule 9 questionnaire response of Adele McGarry, dated 29/05/2024.
Publication Date:
17 February 2025
INQ0101076 – Page 53 of Witness Statement of Susan Gilby, dated 29/05/2024.
Publication Date:
25 February 2025
INQ0102616 – Witness Statement of Dr Simon Kenny, dated 29/05/2024.
Publication Date:
4 March 2025
INQ0101077 – Page 41 of Part 1 of Expert Report of Sir Robert Francis KC, dated 30/05/2024
Publication Date:
9 January 2025
INQ0101363 – Witness Statement of Heather Marie Wilshaw-Jones, dated 30/05/2024
Publication Date:
15 January 2025
INQ0101112 – Pages 3 and 4 of Witness Statement of Susannah Holt (Paediatric Consultant, Countess of Chester Hospital), dated 31/05/2024
Publication Date:
3 October 2024
INQ0017808 – Witness statement of Andrea Sutcliffe, dated 31/05/2024
Publication Date:
9 January 2025
INQ0101319 – Witness Statement on Minna-Maria Lappalainen, dated 31/05/2024.
Publication Date:
17 February 2025
INQ0101118 – Witness statement of Sarah Jayne Murphy, dated 03/06/2024
Publication Date:
16 October 2024
INQ0101322 – Pages 10 – 11 of Witness Statement of Anne McGlade, dated 03/06/2024
Publication Date:
16 October 2024
INQ0101314 – Second Witness Statement of Mike Leaf, dated 03/06/2024.
Publication Date:
15 January 2025
INQ0101111 – Witness Statement of Charles William Yoxall, dated 03/06/2024
Publication Date:
16 January 2025
INQ0101320 - Page 9 of Witness Statement of Margaret Williams, dated 03/06/2024.
Publication Date:
10 September 2025
INQ0101326 – Witness statement of David Semple, dated 06/06/2024
Publication Date:
8 January 2025
INQ0101330 – Rule 9 questionnaire response of Jean Peers, dated 06/06/2024.
Publication Date:
17 February 2025
INQ0101331 – Witness Statement of Mary Griffith, dated 06/06/2024.
Publication Date:
20 February 2025
INQ0101332 – Page 56 of Witness Statement of Ruth Esther Millward (Head of Risk and Patient Safety, Countess of Chester Hospital NHS Foundation Trust), dated 07/06/2024
Publication Date:
1 October 2024
INQ0101380 – Witness statement of Professor Judith Smith, dated 07/06/2024
Publication Date:
9 January 2025
INQ0101414 – Witness statement of Lyn Simpson, dated 11/06/2024
Publication Date:
20 January 2025
INQ0101412 – Witness statement of Dr Amanda Doyle OBE, dated 11/06/2024
Publication Date:
23 January 2025
INQ0102754 – Witness Statement of Professor David Oliver, dated 11/06/2024
Publication Date:
29 January 2025
INQ0102020 – Witness Statement of Martin Leonard Sedgwick, dated 12/06/2024
Publication Date:
16 January 2025
INQ0101420 – Witness Statement of Anne Eden, dated 12/06/2024
Publication Date:
20 January 2025
INQ0102021 – Witness Statement of Dr Astha Vasuveda Soni, dated 12/06/2024.
Publication Date:
17 February 2025
INQ0102015 – Page 8 of Witness Statement of Dr Jo Louise McPartland, dated 13/06/2024
Publication Date:
12 November 2024
INQ0102017 – Exhibit Bundle consisting of: CR/01- Job Description for the Assistant Trust Secretary & Executive Office Manager; CR/02- Executive Team Notes, Minutes of the Executive Directors Group meetings; CR/03- Minutes of the Board of Directors formal meetings; and CR/04- Email from Stephen Cross to Simon Medland, regarding the Neonatal Unit review, update from the Child Death Overview Panel meeting and investigation into the unexplained baby deaths, dated 13/06/2024. Produced by Claire Raggett in the first witness statement at INQ0102018.
Publication Date:
14 January 2025
INQ0102018 – First Witness Statement of Claire Raggett, dated 13/06/2024.
Publication Date:
14 January 2025
INQ0101421 – Witness Statement of Jackie Smith, dated 14/06/2024
Publication Date:
24 January 2025
INQ0102023 – Witness Statement of Dr Kaliyilil Luke George Verghese, dated 14/06/2024.
Publication Date:
4 March 2025
INQ0102039 – Witness Statement of Dr Rhiannon Sian Austin, dated 14/06/2024.
Publication Date:
4 March 2025
INQ0102038 – Pages 13-14 of Witness Statement of Karen Moore (Rees), dated 14/06/2024
Publication Date:
29 August 2025
INQ0102019 – Page 3 of Witness statement of Dr Sally Rebecca Ogden, dated 17/06/2024
Publication Date:
2 October 2024
INQ0102019 – Page 8 of Witness statement of Dr Sally Rebecca Ogden (Specialty Trainee Paediatric Registrar, Countess of Chester Hospital), dated 17/06/2024
Publication Date:
2 October 2024
INQ0102649 – Witness Statement of Sir Stephen Moss, dated 17/06/2024
Publication Date:
24 January 2025
INQ0102019 – Witness Statement of Dr Sally Ogden, dated 17/06/2024.
Publication Date:
4 March 2025
INQ0102072 – Pages 14 – 16 of Witness Statement of Yvonne Griffiths, dated 19/06/2024
Publication Date:
16 October 2024
INQ0102345 – Page 31 of transcript of the criminal trial of R v Letby, dated 19/06/2024
Publication Date:
13 November 2024
INQ0102069 – Witness Statement of Gill Galt, dated 19/06/2024
Publication Date:
14 January 2025
INQ0102070 – Exhibit GG01: Document from the Countess of Chester Hospital titled Draft Policy for Use of Internal Communication Channels, dated 19/06/2024.
Publication Date:
14 January 2025
INQ0102071 – Exhibit GG02: Document from the Countess of Chester Hospital titled Policy for Media Enquiries and Handling, dated 19/06/2024.
Publication Date:
14 January 2025
INQ0101409 – Witness Statement of Dr Wojtek Rakowicz, dated 19/06/2024
Publication Date:
24 January 2025
INQ0102369 – Witness Statement of David Hunter, dated 20/06/2024.
Publication Date:
15 January 2025
INQ0102350 – Witness Statement of Dr David Harkness, dated 20/06/2024.
Publication Date:
17 February 2025
INQ0102352 – Witness Statement of Dr Sudeshna Bhowmik, dated 20/06/2024.
Publication Date:
4 March 2025
INQ0102367 – Pages 6, 13 – 14 and 17 of Witness Statement of Nigel Wenham, Former Detective Chief Superintendent, Cheshire Police, dated 21/06/2024
Publication Date:
20 November 2024
INQ0102349 – Witness Statement of Elizabeth O’Mahony, NHS England, dated 21/06/2024
Publication Date:
24 January 2025
INQ0102351 – Page 10 of Witness Statement of Matthew Neame, dated 23/06/2024
Publication Date:
2 October 2024
INQ0102609 – Disclosure Statement of Ann Ford on behalf of the Care Quality Commission, dated 24/06/2024
Publication Date:
17 January 2025
INQ0102365 – Witness statement of Sarah Harper Lea, dated 24/06/2024
Publication Date:
22 January 2025
INQ0102615 – Rule 9 questionnaire response of Abigail Rebecca Lever, dated 25/06/2024.
Publication Date:
17 February 2025
INQ0102691 – Witness Statement of Dr Lucy Beebe, dated 26/06/2024.
Publication Date:
4 March 2025
INQ0102624 – Expert Report of Professor Mary Dixon-Woods titled Report to the Thirlwall Inquiry: addressing Part C of the Terms of Reference, dated 28/06/2024
Publication Date:
26 September 2024
INQ0108797_158-160 – Pages 158 – 160 of Report by the Review Body on Senior Salaries titled Forty-Sixth Annual Report on Senior Salaries – Report No. 97, dated July 2024
Publication Date:
22 January 2025
INQ0102636 – Witness Statement of Fiona Mary Helen MacRae, dated 02/07/2024.
Publication Date:
25 March 2025
INQ0102689 – Witness statement of Patricia Marquis, dated 03/07/2024.
Publication Date:
15 January 2025
INQ0103247 – Witness Statement of Dr Jeremy M Butcher, dated 03/07/2024.
Publication Date:
25 March 2025
INQ0102748 – Rule 9 questionnaire response of Rachael Wright, dated 04/07/2024.
Publication Date:
20 February 2025
INQ0102749 – Witness Statement of Dr Sara Brigham, dated 04/07/2024.
Publication Date:
4 March 2025
INQ0102753 – Witness statement of Professor Neena Modi, dated 08/07/2024
Publication Date:
7 February 2025
INQ0102757 – Second Disclosure Statement on behalf of the Countess of Chester Hospital made by Claire Elizabeth Raggett, dated 09/07/2024
Publication Date:
13 January 2025
INQ0106962 – Page 12 of Witness statement of Dr Edile Mohammed Nur Murdoch, dated 10/07/2024
Publication Date:
15 January 2025
INQ0106962 – Witness statement of Dr Edile Mohammed Nur Murdoch, dated 10/07/2024
Publication Date:
24 January 2025
INQ0108773 – Pages 1, 6 and 14 of Guidance from the British Association of Perinatal Medicine titled Recognising Uncertainty: An integrated framework for palliative care in perinatal medicine, dated 11/07/2024
Publication Date:
14 January 2025
INQ0103101 – Witness Statement of Dr Simon Greaves, dated 11/07/2024.
Publication Date:
4 March 2025
INQ0103104 - Page 4 of Witness Statement of Dr Stephen Brearey, dated 12/07/2024
Publication Date:
15 September 2025
INQ0103104 – Pages 17, 24, 26, 28, 31, 42 – 43 and 64 – 65 of Witness Statement of Dr Stephen John Brearey, dated 12/07/2024
Publication Date:
19 November 2024
INQ0103104 – Page 33 of Witness Statement of Dr Stephen John Brearey, dated 12/07/2024
Publication Date:
20 November 2024
INQ0103104 - Page 36 of Witness Statement of Dr Stephen Brearey, dated 12/07/2024.
Publication Date:
12 September 2025
INQ0103104 – Pages 39-40 of Witness Statement of Dr Stephen Brearey, dated 12/07/2024
Publication Date:
29 August 2025
INQ0103104 – Page 44 of Witness Statement of Dr Stephen Brearey, dated 12/07/2024
Publication Date:
29 August 2025
INQ0106963 – Witness statement of Dr Joanna Garstang [dated 13/07/2024]
Publication Date:
26 September 2024
INQ0107014 – Disclosure Statement Katherine Ibbotson on behalf of NHS England, dated 16/07/2024.
Publication Date:
17 January 2025
INQ0107960- Witness Statement of Susan Pemberton, dated 16/07/2024.
Publication Date:
17 January 2025
INQ0106972 – Witness Statement of Dr Anthony Ukoh, dated 20/07/2024.
Publication Date:
4 March 2025
INQ0106971 – Witness Statement of Dr Jian Min Hor, dated 22/07/2024.
Publication Date:
4 March 2025
INQ0107028 – Witness Statement of Joanne Williams, dated 23/07/2024.
Publication Date:
17 February 2025
INQ0107032 – Witness Statement of Robert Cornall, Regional Director for Specialised Commissioning, NHS England, dated 24/07/2024.
Publication Date:
16 January 2025
INQ0107908 – Fourth Witness Statement of Professor Sir Stephen Powis on behalf of NHS England, dated 24/07/2024
Publication Date:
17 January 2025
INQ0107016 – Witness Statement of Tom Kark KC, dated 24/07/2024
Publication Date:
20 January 2025
INQ0107034 – Pages 25, 27, 35 and 36 of the witness statement of Michael Gregory, dated 25/07/2024
Publication Date:
29 November 2024
INQ0003245 – Handwritten notes by Ian Harvey of a call with Michael Gregory, dated 25/07/2024.
Publication Date:
16 January 2025
INQ0107034- Witness Statement of Michael Gregory, dated 25/07/2024.
Publication Date:
16 January 2025
INQ0107036 – Witness Statement of Margaret Kitching, dated 25/07/2024
Publication Date:
16 January 2025
INQ0107145 – Witness statement of Dr Joanne Davies, dated 25/07/2024.
Publication Date:
25 March 2025
INQ0107030- Witness Statement of Julie McCabe, dated 28/07/2024.
Publication Date:
15 January 2025
INQ0107011 – Witness Statement of Dr Nick Lessof, dated 29/07/2024
Publication Date:
23 January 2025
INQ0107127 – Witness statement of Lawrence Andrew Dixon, dated 30/07/2024.
Publication Date:
15 January 2025
INQ0107639 – Witness statement of Fiona Murphy, dated 01/08/2024
Source Date:
1 August 2024
Publication Date:
24 January 2025
INQ0107144 – Third Disclosure Statement on behalf of the Countess of Chester Hospital made by Claire Elizabeth Raggett, dated 02/08/2024
Source Date:
2 August 2024
Publication Date:
13 January 2025
INQ0107143 – Witness statement of the Rt Hon Baroness Bottomley of Nettlestone, dated 05/08/2024
Source Date:
5 August 2024
Publication Date:
9 January 2025
INQ0107926 – Witness statement of Helen Herniman, dated 07/08/2024
Source Date:
7 August 2024
Publication Date:
9 January 2025
INQ0107650 – Witness statement of Jane Margaret Evans, dated 08/08/2024
Source Date:
8 August 2024
Publication Date:
8 January 2025
INQ0107911 – Second Disclosure Statement of Ann Ford on behalf of the Care Quality Commission, dated 08/08/2024
Source Date:
8 August 2024
Publication Date:
17 January 2025
INQ0107683 – Witness Statement of Nurse Y, dated 09/08/2024.
Source Date:
9 August 2024
Publication Date:
20 February 2025
INQ0107651 – Page 18-20 of Witness Statement of Ian Pace, dated 09/08/2024
Source Date:
9 August 2024
Publication Date:
11 September 2025
INQ0107653 – Pages 25, 30-31 & 33 of Witness Statement of Ian Harvey, dated 11/08/2024
Source Date:
11 August 2024
Publication Date:
29 August 2025
INQ0107653 – Page 27 of Witness Statement of Ian Harvey, dated 11/08/2024
Source Date:
11 August 2024
Publication Date:
9 September 2025
INQ0107653 – Page 40 of Witness Statement of Ian Harvey, dated 11/08/2024
Source Date:
11 August 2024
Publication Date:
1 September 2025
INQ0107653 – Page 68 of Witness Statement of Ian Harvey, dated 11/08/2024
Source Date:
11 August 2024
Publication Date:
29 August 2025
INQ0107704 - Page 72 of Witness Statement of Alison Kelly, dated 13/08/2024.
Source Date:
13 August 2024
Publication Date:
12 September 2025
INQ0107704 – Pages 78-79 of Witness Statement of Alison Kelly, dated 13/08/2024
Source Date:
13 August 2024
Publication Date:
29 August 2025
INQ0107704 – Pages 90-91 of Witness Statement of Alison Kelly, dated 13/08/2024
Source Date:
13 August 2024
Publication Date:
29 August 2025
INQ0108007 – Witness Statement of William Vineall, on behalf of the Department for Health and Social Care, dated 14/08/2024
Source Date:
14 August 2024
Publication Date:
16 January 2025
INQ0107707 – Witness Statement of Stephen Paul Cross, dated 15/08/2024
Source Date:
15 August 2024
Publication Date:
17 January 2025
INQ0107826 – Witness Statement of Kate Meynell, dated 19/08/2024
Source Date:
19 August 2024
Publication Date:
24 January 2025
INQ0107824 – Witness Statement of Belinda Williamson (nee Simcock), dated 19/08/2024.
Source Date:
19 August 2024
Publication Date:
20 February 2025
INQ0107825 – Witness Statement of Dr James Smith, dated 19/08/2024.
Source Date:
19 August 2024
Publication Date:
25 March 2025
INQ0107827 – Witness statement of the Rt Hon Jeremy Hunt MP, dated 20/08/2024
Source Date:
20 August 2024
Publication Date:
9 January 2025
INQ0107962- Page 121 of Witness Statement of Dr Jayaram, dated 30/08/2024
Source Date:
30 August 2024
Publication Date:
13 November 2024
INQ0107964 – Pages 5, 13, 18, 22, 24, 77, 80, 172, 213, 239, 263 and 269 of Ravi Jayaram’s exhibit bundle, dated 30/08/2024
Source Date:
30 August 2024
Publication Date:
13 November 2024
INQ0107940 – Witness Statement of William Vineall, on behalf of the Department for Health and Social Care, dated 30/08/2024
Source Date:
30 August 2024
Publication Date:
16 January 2025
INQ0108670 – Guidance from MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK, titled perinatal mortality surveillance – user guide for perinatal and infant death data entry and reports v2.0, dated September 2024
Source Date:
1 September 2024
Publication Date:
7 January 2025
INQ0107981 – Witness Statement of Dr Claire Thomas, Public Health Wales, dated 06/09/2024
Source Date:
6 September 2024
Publication Date:
3 October 2024
INQ0107971- Second Witness Statement of Emma Kate Taylor, dated 06/09/2024.
Source Date:
6 September 2024
Publication Date:
14 January 2025
INQ0107982 – Witness Statement of Dr Veronika Jiraskova, dated 06/09/2024.
Source Date:
6 September 2024
Publication Date:
4 March 2025
INQ0108003 – Witness Statement provided by Erica Saunders, Director of Corporate Affairs, Alder Hey Children’s NHS Foundation Trust, dated 09/09/2024
Source Date:
9 September 2024
Publication Date:
7 October 2024
INQ0108030 – Extract of The Times Newspaper titled ‘Duty of candour’, dated 25/09/2024
Source Date:
25 September 2024
Publication Date:
30 September 2024
INQ0108335 – Pages 1 – 2 of Supplementary Witness Statement of Yvonne Griffiths, Nurse, Neonatal Unit Manager, Countess of Chester Hospital, dated 15/10/2024
Source Date:
15 October 2024
Publication Date:
16 October 2024
INQ0108375 – Third Witness Statement of Ann Ford on behalf of the Care Quality Commission, dated 18/10/2024
Source Date:
18 October 2024
Publication Date:
17 January 2025
INQ0108372 – Witness Statement of Dr Rosie Benneyworth, dated 23/10/2024
Source Date:
23 October 2024
Publication Date:
8 January 2025
INQ0108378 – Witness Statement of Joyce Frederick on behalf of the Care Quality Commission, dated 24/10/2024
Source Date:
24 October 2024
Publication Date:
17 January 2025
INQ0108585 – Second Witness Statement of Stuart Lythgoe on behalf of the Hospital Consultants and Specialists Association, dated 24/10/2024
Source Date:
24 October 2024
Publication Date:
17 January 2025
INQ0108385 – Witness Statement of Kirstin Hannaford, dated 30/10/2024
Source Date:
30 October 2024
Publication Date:
10 January 2025
INQ0108409 – Witness statement of Professor Sam Shuster, dated 31/10/2024
Source Date:
31 October 2024
Publication Date:
24 January 2025
INQ0108403 – Supplementary Witness Statement of Sarah Harper Lea (Head of Legal Services, Countess of Chester Hospital), dated 04/11/2024.
Source Date:
4 November 2024
Publication Date:
22 January 2025
INQ0108424 – Witness Statement of Kirstin Hannaford, dated 06/11/2024
Source Date:
6 November 2024
Publication Date:
10 January 2025
INQ0108437 – Witness statement of Helen Herniman, dated 07/11/2024
Source Date:
7 November 2024
Publication Date:
9 January 2025
INQ0108452- Witness Statement of Kristian Garsed, dated 08/11/2024.
Source Date:
8 November 2024
Publication Date:
17 January 2025
INQ0108478 – Second Witness Statement of Claire Elizabeth Raggett, dated 12/11/2024.
Source Date:
12 November 2024
Publication Date:
13 January 2025
INQ0108481 - Page 6 of Witness Statement of Joshua Swash, dated 12/11/2024
Source Date:
12 November 2024
Publication Date:
12 September 2025
INQ0108513 – Second Witness Statement of Charles William Yoxall, dated 14/11/2024
Source Date:
14 November 2024
Publication Date:
16 January 2025
INQ0108592 – Fourth Disclosure Statement on behalf of the Countess of Chester Hospital made by Claire Elizabeth Raggett, dated 19/11/2024
Source Date:
19 November 2024
Publication Date:
13 January 2025
INQ0108591 -Witness Statement of Nicola Lyon, dated 19/11/2024
Source Date:
19 November 2024
Publication Date:
24 January 2025
INQ0108598 – Witness Statement of John Bowers KC, dated 27/11/2024
Source Date:
27 November 2024
Publication Date:
24 January 2025
INQ0108672 – Page 1 of Consultation from the Department of Health and Social Care titled Leading the NHS: proposals to regulate NHS managers, dated 28/11/2024
Source Date:
28 November 2024
Publication Date:
17 January 2025
INQ0108782 – Pages 1 – 5 of Table produced by the Inquiry Legal Team titled ‘All of the neonatal deaths linked to the Countess of Chester Hospital in 2015 and 2016’, dated December 2024
Source Date:
1 December 2024
Publication Date:
13 January 2025
INQ0108656 – Witness statement of Professor Turner, dated 02/12/2024
Source Date:
2 December 2024
Publication Date:
17 December 2024
INQ0108659 – Witness Statement of Dr Alan Fletcher, dated 06/12/2024
Source Date:
6 December 2024
Publication Date:
28 January 2025
INQ0108669 – Witness Statement of Chris Dzikiti, on behal of the Care Quality Commission, dated 09/12/2024
Source Date:
9 December 2024
Publication Date:
29 January 2025
INQ0108674 -Witness statement of Ann Ford (Director of Operations Network North, Care Quality Commission), dated 11/12/2024
Source Date:
11 December 2024
Publication Date:
14 January 2025
INQ0108677 – Fourth witness statement to the Thirlwall Inquiry of Jane Tomkinson (Chief Executive Officer, Countess of Chester NHS Foundation Trust), dated 11/12/2024.
Source Date:
11 December 2024
Publication Date:
21 March 2025
INQ0108715 - Page 4 of Second Witness Statement of Ruth Millward, dated 12/12/2024
Source Date:
12 December 2024
Publication Date:
15 September 2025
INQ0108740 – Pages 1, 6 – 8 and 23 – 24 of Report from the Department of Health & Social Care titled Investigating Healthcare Incidents Where Suspected Criminal Activity May Have Contributed To Death Or Serious Life-Changing Harm, dated 17/12/2024
Source Date:
17 December 2024
Publication Date:
15 January 2025
INQ0108740 – Pages 1, 4 and 7 of Report from the Department of Health & Social Care titled Investigating Healthcare Incidents Where Suspected Criminal Activity May Have Contributed To Death Or Serious Life-Changing Harm, dated 17/12/2024
Source Date:
17 December 2024
Publication Date:
17 January 2025
INQ0108742 – Witness Statement of Lisa Annaly, dated 18/12/2024
Source Date:
18 December 2024
Publication Date:
17 January 2025
INQ0108723 – Page 3 of Second Witness Statement of Tony Chambers, dated 18/12/2024
Source Date:
18 December 2024
Publication Date:
29 August 2025
INQ0108723 - Page 8 of Second Witness Statement of Tony Chambers, dated 18/12/2024
Source Date:
18 December 2024
Publication Date:
15 September 2025
INQ0108738 – Witness statement of Charles Hamilton Massey, on behalf of the General Medical Council, dated 19/12/2024
Source Date:
19 December 2024
Publication Date:
29 January 2025
INQ0108743 – Witness Statement of Lyn Andrews, dated 20/12/2024
Source Date:
20 December 2024
Publication Date:
17 January 2025
INQ0108744 – Second Witness statement of Dr Edile Mohammed Nur Murdoch, dated 22/12/2024
Source Date:
22 December 2024
Publication Date:
7 January 2025
INQ0108744 – Page 7 of Witness statement of Dr Edile Mohammed Nur Murdoch, dated 22/12/2024
Source Date:
22 December 2024
Publication Date:
15 January 2025
INQ0108781 – Page 1 of Document from the Inquiry Legal Team titled Countess of Chester Evidence about the number of deaths on the neonatal unit Pre-2015, dated January 2025
Source Date:
1 January 2025
Publication Date:
13 January 2025
INQ0108781 – Document from the Inquiry Legal Team titled Countess of Chester Evidence about the number of deaths on the neonatal unit Pre-2015, dated January 2025
Source Date:
1 January 2025
Publication Date:
13 January 2025
INQ0108747 – Witness statement of Professor Judith Smith, dated 03/01/2025
Source Date:
3 January 2025
Publication Date:
9 January 2025
INQ0108775 – Document titled Medical Examiner System – chronology. Produced by the Inquiry Legal Team, dated 09/01/2025
Source Date:
9 January 2025
Publication Date:
9 January 2025
INQ0108777 – Witness Statement of Rosemary Agnew, Scottish Public Services Ombudsman, dated 09/01/2025
Source Date:
9 January 2025
Publication Date:
28 January 2025
INQ0108786 – Witness statement of Professor Sir David Spiegelhalter, dated 15/01/2025
Source Date:
15 January 2025
Publication Date:
15 January 2025
INQ0108834 – Witness Statement of Dr Rosie Benneyworth, on behalf of the Health Services Safety Investigations Body (HSSIB), dated 21/01/2025
Source Date:
21 January 2025
Publication Date:
28 January 2025
INQ0108837 – Witness Statement of Charles Hamilton Massey, on behalf of the General Medical Council, dated 22/01/2025
Source Date:
22 January 2025
Publication Date:
29 January 2025
INQ0108838 – Witness Statement of Helene Donnelly, dated 23/01/2025
Source Date:
23 January 2025
Publication Date:
28 January 2025
INQ0108843 – Witness Statement of Helen Herniman, on behalf of the Nursing and Midwifery Council, dated 24/01/2025
Source Date:
24 January 2025
Publication Date:
28 January 2025
INQ0108866 – Second witness statement of Chris Dzikiti (Interim Chief Inspector of Healthcare, Care Quality Commission), dated 05/02/2025.
Source Date:
5 February 2025
Publication Date:
21 March 2025
INQ0108867 – Fourth witness statement provided by William Vineall on behalf of the Department for Health and Social Care, dated 05/02/2025.
Source Date:
5 February 2025
Publication Date:
21 March 2025
INQ0108868 – Third witness statement of Patricia Marquis (Director for England, Royal College of Nursing), dated 06/02/2025.
Source Date:
6 February 2025
Publication Date:
21 March 2025
INQ0108888 – Witness statement of Dr Ngozi Edi-Osagie (National Clinical Director, Neonatal Care), dated 10/02/2025.
Source Date:
10 February 2025
Publication Date:
21 March 2025
INQ0108901 – Pages 1 and 3 of Employment Tribunal decision before Employment Judge Shotter, Ms M Plimley and Mr J Murdie, of Dr Susan Gilby v (1) Countess of Chester Hospital and (2) Ian Haythronthwaite, dated 12/02/2025.
Source Date:
12 February 2025
Publication Date:
25 February 2025
INQ0108893 – Third witness statement of Professor Judith Smith (Professor of Health Policy and Management, University of Birmingham Health Services Management Centre), dated 13/02/2025.
Source Date:
13 February 2025
Publication Date:
21 March 2025
INQ0108894 – Second witness statement of Professor Sam Shuster, dated 13/02/2025.
Source Date:
13 February 2025
Publication Date:
21 March 2025
INQ0108914 – Fifth Witness Statement of Claire Raggett, dated 03/03/2025.
Publication Date:
25 March 2025
INQ0108918 – Third witness statement provided by Robert Okunnu (Chief Executive Officer, Royal College of Paediatrics and Child Health) on behalf of the Royal College of Paediatricians and Child Health, dated 04/03/2025.
Publication Date:
21 March 2025
INQ0108920 – Third witness statement of Duncan Burton (Deputy Chief Nursing Officer for England, National Health Service), dated 07/03/2025.
Publication Date:
21 March 2025
INQ0108937 – Witness statement of Jennifer Collard (Head of Regulatory Policy, Nursing and Midwifery Council), on behalf of the Nursing and Midwifery Council, dated 17/03/2025.
Source Date:
17 March 2025
Publication Date:
21 March 2025
INQ0108952 - Pages 4 - 5 of Witness Statement of Stephen Cross, dated 31/03/2025
Source Date:
31 March 2025
Publication Date:
12 September 2025
INQ0101078 – Appendices to the Expert Report of Sir Robert Francis KC
Publication Date:
30 September 2024
INQ0101077 – Expert Report of Sir Robert Francis KC – Part 1
Publication Date:
30 September 2024
INQ0101079 – Expert Report of Sir Robert Francis KC – Part 2
Publication Date:
30 September 2024
INQ0000108 – Page 178 of Medical Records of [Child C]
Publication Date:
1 October 2024
INQ0013225 – Pages 1 and 9 of Pan-Cheshire Guidelines for The Management of Sudden Unexpected Death in Infants and Children (SUDIC)
Publication Date:
1 October 2024
INQ0006725 – Pages 1 and 9 of table of paediatric consultant concerns and responses from Tony Chambers
Publication Date:
3 October 2024
INQ0000859 – Pages 39 and 334 of Medical Records for [Child F]
Publication Date:
7 October 2024
INQ0006458 – Page 1 of PowerPoint presentation titled ‘Analysis of NNU Mortality Rates’
Publication Date:
7 October 2024
INQ0012016 – Pages 1 and 4 of Pan-Lancashire Child Death Overview Panel, Neonatal Deaths Form A/B
Publication Date:
7 October 2024
INQ0100851 – Page 2 -3 of document created by Doctor U for Letby’s revalidation regarding her observation visits at Alder Hey Hospital
Publication Date:
7 October 2024
INQ0098143 – Pages 1 – 2 of document titled Medical Staff Committee of the Countess of Chester NHS Foundation Trust, providing a constitution of the committee
Publication Date:
8 October 2024
INQ0003174 – Page 29 and 31 of email correspondence regarding Silver Control Briefing Note and briefing note titled 12:30pm Briefing for CSCs & On-Call Managers Actions
Publication Date:
9 October 2024
INQ0014042 – Pages 163 – 165 and 170 – 171 of Letby’s student file from the University of Chester, including her final assessment of proficiency and placement progress sheet
Publication Date:
16 October 2024
INQ0003089 – Page 1 of email correspondence between Eirian Powell and Alison Kelly regarding the thematic review, dated 17/03/1016
Publication Date:
17 October 2024
INQ0003138 – Page 2 of email correspondence between Eirian Powell and Alison Kelly regarding the thematic review, dated 14/03/1016
Publication Date:
17 October 2024
INQ0057499 – email correspondence from Letby to Ian Harvey, Karen Rees and Hayley Cooper relating to Letby’s involvement in deaths, 09/01/2017
Publication Date:
21 October 2024
INQ0003251 – Page 9 of Document titled Thematic Review of Neonatal Mortality 2015-Jan 2016
Publication Date:
22 October 2024
INQ0006466 – Page 1 – 3 and 9 of Document from Countess of Chester Hospital titled Policy for the Reporting of Incidents
Publication Date:
22 October 2024
INQ0010022 – Pages 1 – 3 of Dcoument from Countess of Chester Hospital titled Policy for the Reporting of Incidents
Publication Date:
22 October 2024
INQ0001888 – Pages 1 and 8 of Draft Paper from the Countess of Chester Hospital titled Position Paper – Neonatal Unit Mortality 2013-2016
Publication Date:
4 November 2024
INQ0003324 – Pages 15 – 16 of Policy from Countess of Chester Hospital titled Guidelines for the Conduct of Formal Investigations
Publication Date:
4 November 2024
INQ0006466 – Pages 1 and 3 of Policy from Countess of Chester Hospital titled Policy for the Reporting of Incidents
Publication Date:
4 November 2024
INQ0014962 – Pages 1, 3 – 5 and 9 of Policy from Countess of Chester Hospital titled Risk Management Strategy & Operational Policy
Publication Date:
4 November 2024
INQ0103833 – Operational Management Structure of the Urgent Care Division at the Countess of Chester Hospital
Publication Date:
4 November 2024
INQ0002879 – Appendix 6 to Disciplinary Policy, titled ‘Consideration of Referral to the Local Authority Designated Officer (LADO) (Disclosure and Barring Service (DBS))
Publication Date:
5 November 2024
INQ0003012 – Pages 1, 9 and 11 – 12 of Speak Out Safely and Whistle Blowing Policy
Publication Date:
5 November 2024
INQ0012622 – Schedule of parents spoken to by Alison Kelly and Sian Williams on 03/02/2017
Publication Date:
5 November 2024
INQ0108329 – Pages 1 and 15 of Disciplinary Policy for the Countess of Chester NHS Foundation Trust
Publication Date:
5 November 2024
INQ0014165 – Policy from the Countess of Chester Hospital titled Safeguarding and Promoting the Welfare of Children
Publication Date:
6 November 2024
INQ0102688 – Page 2 of Advice from the Royal College of Nursing titled Raising concerns: a guide for RCN members
Publication Date:
6 November 2024
INQ0002879 – Pages 3, 9, 30, 38, 47 – 48, 51 – 52, 54, 59, 63 – 64, 199, 217 – 219 and 221 of Letby’s grievance file
Publication Date:
7 November 2024
INQ0003012 – Pages 1 and 2 of the Countess of Chester’s Speak Out Safely (Raising Concerns About Patient Care) and Whistle Blowing Policy
Publication Date:
7 November 2024
INQ0010072 – Sheet 1 of Report from the Countess of Chester Hospital, mapping staff members on duty
Publication Date:
7 November 2024
INQ0010256 – Page 1 of Royal College of Paediatrics and Child Health’s Draft Terms of Reference, relating to the review of the Countess of Chester neonatal unit
Publication Date:
7 November 2024
INQ0108329 – Page 15 of Countess of Chester’s Disciplinary Policy
Publication Date:
7 November 2024
INQ0009628 – Pages 1 – 2 of form from Royal College of Paediatrics and Child Health titled QA form for reports, by Dr Wilson, regarding the invited review of neonatal services
Publication Date:
11 November 2024
INQ0013235 – Pages 54 – 55 of Guidance titled Working Together to Safeguard Children
Publication Date:
11 November 2024
INQ0002045 – Pages 4, 7 – 8 and 831 – 834 of Bundle of coronial materials in relation to [Child D]
Publication Date:
12 November 2024
INQ0102007 – Pages 3 – 4 of email correspondence including a summary of Countess of Chester cases reviewed by Dr McPartland, Dr Kokai and Dr Shukla
Publication Date:
12 November 2024
INQ0000017 – Page 18 – 19 of Medical Records of [Child A]
Publication Date:
13 November 2024
INQ0002879 – Pages 10 and 47 – 48 of Letby’s grievance file
Publication Date:
13 November 2024
INQ0004356 – Page 3 of Transcript of online advice between Ravi Jayaam [Jayaram] and British Medical Association
Publication Date:
13 November 2024
INQ0106785 – Pages 7, 10 – 12 and 19 of CQC Inspection Framework for NHS Acute Hospitals
Publication Date:
14 November 2024
INQ0017287 – Pages 1, 2 and 3 of Table prepared by the Care Quality Commission titled “Core Interviews and Focus Groups – Countess of Chester Hospital” in 2016
Publication Date:
15 November 2024
INQ0001943 [correction: INQ0001942] – Pages 1 and 6 of Form B Agency Report Form relating to [Child A]
Publication Date:
18 November 2024
INQ0001944 – Pages 1, 3 and 5 of Pan-Cheshire CDOP Form C Analysis Pro-forma in relation to [Child A]
Publication Date:
18 November 2024
INQ0001946 – Pages 1, 3 and 5 of Form C Analysis Pro-forma from the Cheshire Pan-Cheshire Child Death Overview Panel in relation to [Child I]
Publication Date:
18 November 2024
INQ0001954 – Page 20 of RCPCH report
Publication Date:
18 November 2024
INQ0004715 – Pages 1, 7 and 19 of Safeguarding Annual Report 2016-17
Publication Date:
18 November 2024
INQ0014165 – Pages 1, 3 – 4, 11, 30 and 32 of the Countess of Chester’s Safeguarding Policy
Publication Date:
18 November 2024
INQ0014575 – Pages 52, 54 and 57 of Working Together Policy
Publication Date:
18 November 2024
INQ0102620 – Pages 17 and 22 of Safeguarding Strategy Board’s Terms of Reference
Publication Date:
18 November 2024
INQ0007918 – Page 1 of Guidance titled Thresholds for Initiating Safeguarding Procedures
Publication Date:
18 November 2024
INQ0002837 – Pages 1, 2 and 5 of a PowerPoint presentation, regarding NNU mortality, NNU deaths and acuity, undated
Publication Date:
19 November 2024
INQ0003530 – Page 1 of Handwritten note titled ‘SUI Review’ relating to the deaths of [Child A], [Child C] and [Child D]
Publication Date:
19 November 2024
INQ0012979 – Pages 23 – 24 of Facere Melius interview with Dr Brearey
Publication Date:
19 November 2024
INQ0103194 – Pages 1 and 2 of Executive Summary from Dr Stephen Brearey, regarding the National Neonatal Audit Programme Report for 2015, dated 2016
Publication Date:
19 November 2024
INQ0103210 – Pages 1, 4 and 15 of Annual Report for the Countess of Chester Neonatal Unit January – December 2016, undated
Publication Date:
19 November 2024
INQ0103225 – Pages 1 – 3 of Document from the Countess of Chester Hospital titled Mortality, Acuity and Staffing 2015-2016, dated 2017
Publication Date:
19 November 2024
INQ0108346 – Page 45 of Training Presentation from the Countess of Chester Hospital, Flow chart entitled “What to do if you’re worried a child is being abused”
Publication Date:
19 November 2024
INQ0108408 – Page 41 and 45 – Child Death Guidance checklist
Publication Date:
19 November 2024
INQ0006466 – Pages 1 – 7 of Description Policy from Countess of Chester Hospital titled Policy for the Reporting of Incidents
INQ0000108 – Pages 178 – 179 of [Child C]’s Medical Records
Publication Date:
20 November 2024
INQ0001944 – Pages 1 and 5 of Form C for [Child A]
Publication Date:
20 November 2024
INQ0004715 – Page 19 of Safeguarding Children Annual Report 2016 – 2017
Publication Date:
20 November 2024
INQ0102288 – Pages 2, 5, 8 and 13 of Governing Protocol for pan-Cheshire CDOP, dated 2014
Publication Date:
20 November 2024
INQ0102298 – Notes of a meeting between Cheshire Police, including Nigel Wenham, Tony Chambers, Stephen Cross and Ian Harvey, 05/05/2017
Publication Date:
20 November 2024
INQ0102303 – Pages 2 – 4 of Report titled Mortality Acuity and Staffing 2015 to 2016
Publication Date:
20 November 2024
INQ0102684 – Page 10 – Neonatal Steering Group Terms of Reference
Publication Date:
20 November 2024
INQ0014378 – Page 1 – 4 of Document titled Neonatal Services at the Countess of Chester Hospital NHS FT
Publication Date:
21 November 2024
INQ0101357 – Pages 1 – 5, 10 – 11 and 24 of Chronology from correspondence involving Lyn Simpson in September 2018
Publication Date:
21 November 2024
INQ0003172 – Page 44 – Extract of Dr Hawdon’s report
Publication Date:
25 November 2024
INQ0003217 – Pages 1 – 4 and 7 of Thematic Review
Publication Date:
25 November 2024
INQ0014171 – Pages 1 – 2 and 9 of Countess of Chester’s Speak Out Safely (Raising Concerns About Patient Care) and Whistle Blowing Policy
Publication Date:
25 November 2024
INQ0015537 – Page 4 of Handwritten notes of Alison Kelly of two meetings at 10:00 and 16:30 on 27/06/2016
Publication Date:
25 November 2024
INQ0106930 – Page 125 of handwritten note by Alison Kelly of call with Gill Frame
Publication Date:
25 November 2024
INQ0002677 – Page 1 of document titled Information from the Countess of Chester Hospital NHS Foundation Trust re neonatal services
Publication Date:
26 November 2024
INQ0002879 – Pages 99 – 100 – Grievance Policy
Publication Date:
26 November 2024
INQ0003012 – Pages 1, 3 and 6 – 8 of Policy titled Safeguarding and Promoting the Welfare of Children [Speak Out Safely Policy]
Publication Date:
26 November 2024
INQ0003014 – Page 2 of Countess of Chester’s ‘Speak Out Safely (Raising Concerns About Patient Care) and Whistle Blowing Policy’
Publication Date:
26 November 2024
INQ0004660 – Pages 1 – 2 of document titled NNU Options Appraisal 08/09/2016
Publication Date:
26 November 2024
INQ0008964 – Pages 83 – 84 – Letter from Sue Hodkinson to Letby, dated
Publication Date:
26 November 2024
INQ0014135 – Page 8 of Document titled 2016 Security Risk Assessment
Publication Date:
26 November 2024
INQ0102205 – Pages 1 – 2 of Telephone Note of call beteen Ian Pace and Sue Hodkinson
Publication Date:
26 November 2024
INQ0101357 – Pages 1 – 2 of Chronology of correspondence involving Lyn Simpson – September 2018
Publication Date:
27 November 2024
INQ0002837 – Pages 2 – 3 of PowerPoint presentation titled “Analysis of NNU Mortality Rates”, undated. [File name indicates date of 08/07/2016].
Publication Date:
28 November 2024
INQ0003014 – Pages 1 – 2 and 10 of Speak Out Safely (Raising Concerns About Patient Care) and Whistle Blowing Policy
Publication Date:
28 November 2024
INQ0003200 – Pages 1 – 3 of Executive Directors Group Meeting Minutes dated 09/09/215
Publication Date:
28 November 2024
INQ0009236 – Pages 15 and 33 – 34 of NHS England’s Serious Incident Framework
Publication Date:
28 November 2024
INQ0014165 – Page 3 and 30 of Policy titled Safeguarding and Promoting the Welfare of Children
Publication Date:
28 November 2024
INQ0014204 – Page 2 of STEIS Report for Baby D
Publication Date:
28 November 2024
INQ0014962 – Pages 1 – 2, 9 and 14 of Risk Management Strategy & Operational Policy
Publication Date:
28 November 2024
INQ0103210 – Page 4 of Document titled “Annual Report for the Countess of Chester Neonatal Unit January – December 2016”, undated.
Publication Date:
28 November 2024
INQ0010256 – Draft Terms of Reference of the ‘Review of the Neonatal Unit at the Countess of Chester NHS FT, under the Invited Review Mechanism of the RCPCH’
Publication Date:
29 November 2024
INQ0062339 – Page 1 of notes of a review of [Child P]’s care
Publication Date:
29 November 2024
INQ0103192 – Page 1 of email correspondence between Nim Subhedar and Ian Harvey, entitled ‘NNU review’, between 08/02/2017 – 27/02/2017
Publication Date:
29 November 2024
INQ0003014 – Pages 2 and 9 of Speak Out Safely Policy
Publication Date:
2 December 2024
INQ0009246 – Pages 1, 12 – 13, 17 – 22 and 31 of the NHS code of governance
Publication Date:
2 December 2024
INQ0009485, – Pages 1, 3 and 30 of Safeguarding and Promoting the Welfare of Children Policy
Publication Date:
2 December 2024
INQ0014818 – Page 157 – Board Assurance Framework – Quarter 1 2016/17
Publication Date:
2 December 2024
INQ0014962 – Pages 1, 3 – 4 and 13 of Risk Management Strategy & Operational Policy
Publication Date:
2 December 2024
INQ0017497 – Page 135 of Clothier report
Publication Date:
2 December 2024
INQ0101079 – Page 60 of Part Two of the Expert Report of Sir Robert Francis KC
Publication Date:
2 December 2024
INQ0101357 – Pages 1 and 24 of correspondence log involving Lyn Simpson for the period of September 2018
Publication Date:
2 December 2024
INQ0102361 – Pages 101 – 102 of Document titled confirmation of employment response
Publication Date:
2 December 2024
INQ0102361 – Page 87 – Response to questions raised by the consultant paediatricians on 30th April 2018
Publication Date:
2 December 2024
INQ0108477 – Pages 1 and 5 of Code of Conduct, Code of Accountability in the NHS
Publication Date:
2 December 2024
INQ0003014 – Pages 6 and 14 of Speak Out Safely (Raising Concerns About Patient Care) and Whistle Blowing Policy
Publication Date:
3 December 2024
INQ0009246 – Pages 1, 13, 17 – 18 and 31 – 32 of The NHS Foundation Trust Code of Governance
Publication Date:
3 December 2024
INQ0014605 – Pages 21 – 22 of the RCPCH interview notes
Publication Date:
3 December 2024
INQ0002048 – Page 89 of document titled ‘Summary of cases’
Publication Date:
4 December 2024
INQ0003101 – Letter to Dr Hawdon
Publication Date:
4 December 2024
INQ0008638 – Pages 1 – 4 of Guidance from the Countess of Chester Hospital NHS Foundation Trust titled Guidance on Writing Witness Statements for unexpected deaths, claims for clinical negligence and court hearings
Publication Date:
4 December 2024
INQ0108392 – Page 1 of Letter from Countess of Chester titled “Inquest Investigations”
Publication Date:
4 December 2024
INQ0013295, – Page 1 of survey from Hospital Consultants and Specialists Association titled “Hospital doctors’ experiences of whistleblowing”
Publication Date:
5 December 2024
INQ0002048 – Pages 89 – 90 – Summary of cases
Publication Date:
6 December 2024
INQ0008638 – Pages 1 – 4 of Guidance on Writing Statements
Publication Date:
6 December 2024
INQ0008841 – Pages 1 – 8 of Thematic Review of Neonatal Mortality 2015 – Jan 2016
Publication Date:
6 December 2024
INQ0008941 – Page 24 of Advice to doctors asked to provide HM Coroner with medical report
Publication Date:
6 December 2024
INQ0009618 – Pages 8 – 10 of Copy of Royal College of Paediatric and Child Health Review
Publication Date:
6 December 2024
INQ0017840 – Pages 1 – 5 of Guidance on reporting deaths to the Coroner
Publication Date:
6 December 2024
INQ0012813 – Pages 13 – 14 of Escalation Policy
Publication Date:
12 December 2024
INQ0012276 – Pages 1 – 2 and 4 of Manchester Patient Safety Framework Tool
Publication Date:
13 December 2024
INQ0014541 – Report by the Parliamentary and Health Service Ombudsman titled ‘Making Complaints Count: Supporting complaints handling in the NHS and UK Government Departments’
Publication Date:
17 December 2024
INQ0014545 – Report by the Parliamentary and Health Service Ombudsman titled ‘Broken trust: making patient safety more than just a promise’
Publication Date:
17 December 2024
INQ0006748 – Paper by MBRRACE-UK titled ‘Explanation of the different mortality rates calculated by MBRRACE’
Publication Date:
7 January 2025
INQ0006755 – Screenshot by MBRRACE-UK of data viewer for Trusts and Health Boards
Publication Date:
7 January 2025
INQ0012447 – Page 164 of Report from the Department of Health and Social Care titled “Learning from Bristol: The Department of Health’s Response to the Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995”, January 2002
Publication Date:
7 January 2025
INQ0102043 – Page 1 of Briefing from Dr Edile Murdoch to Professor Marian Knight titled ‘Proposal to work in partnership with MBRRACE-UK on developing Standard Operating Procedures for the MBRRACE-UK and Reading the signals real time data monitoring tools and to include use of the tool in NHS England’s Perinatal Quality Surveillance Model’
Publication Date:
7 January 2025
INQ0108022 – Pages 1 and 45 of Document titled ‘Bristol Royal Infirmary Inquiry.’ Produced for the Thirlwall Inquiry’s Table of Recommendations, updated in September 2024
Publication Date:
7 January 2025
INQ0010447 – Pages 1 – 2 of Article titled Patient safety regulation in the NHS: mapping the regulatory landscape of healthcare
Publication Date:
8 January 2025
INQ0108364 – Pages 2 – 3 of table from NHS England and the Department of Health and Social Care titled Messenger Review of NHS leadership
Publication Date:
8 January 2025
INQ0108673 – Pages 1 – 2 of Guidance from the NHS England website regarding the NHS Management and leadership programme
Publication Date:
8 January 2025
INQ0108741 – Pages 2 – 4 of Report from the Health Services Safety Investigations Body titled Recommendations But No Action: Improving Effectiveness Of Quality And Safety Recommendations In Healthcare, dates 16/09/2024
Publication Date:
8 January 2025
INQ0108369 – Page 20 of Report from NHS England and the Department of Health and Social Care titled Morecambe Bay investigation, including table of recommendations
Publication Date:
9 January 2025
INQ0108377 – Employer Link Service (ELS) statement of concerns arisen from the opening statement and Nursing and Midwifery Council (NMC) submission of evidence to the Thirlwall Inquiry
Publication Date:
9 January 2025
INQ0108741 – Pages 1, 3 – 4 and 7 of Report from the Health Services Safety Investigations Body titled Recommendations But No Action: Improving Effectiveness Of Quality And Safety Recommendations In Healthcare, dates 16/09/2024
Publication Date:
9 January 2025
INQ0004505 – Safeguarding Children Annual Report, 2015-2016
Publication Date:
10 January 2025
INQ0004715 – Countess of Chester Annual Safeguarding Report, 2016 – 2017
Publication Date:
10 January 2025
INQ0013041- Minutes from the Incident Coordination Panel Meeting, regarding ongoing criminal investigation
Publication Date:
10 January 2025
INQ0014138 – ‘Duty of Candour’ Policy page 1
Publication Date:
13 January 2025
INQ0014139 – ‘Duty of Candour’ Policy page 2
Publication Date:
13 January 2025
INQ0014140 – ‘Duty of Candour’ Policy page 3
Publication Date:
13 January 2025
INQ0014141 – ‘Duty of Candour’ Policy page 4
Publication Date:
13 January 2025
INQ0014142 – ‘Duty of Candour’ Policy page 5
Publication Date:
13 January 2025
INQ0014143 – ‘Duty of Candour’ Policy page 6
Publication Date:
13 January 2025
INQ0014144 – ‘Duty of Candour’ Policy page 7
Publication Date:
13 January 2025
INQ0014145 – ‘Duty of Candour’ Policy page 8
Publication Date:
13 January 2025
INQ0014146 – ‘Duty of Candour’ Policy page 9
Publication Date:
13 January 2025
INQ0014153 – Pages 1 – 5 and 12 -13 of Handling complaints policy
Publication Date:
13 January 2025
INQ0014171 – Pages 1 – 6 of ‘Raising Concerns’ policy
Publication Date:
13 January 2025
INQ0014172 – Pages 1 – 10 of Freedom to Speak Up Policy
Publication Date:
13 January 2025
INQ0014186 – Pages 1, 4, 10, 14 – 15 and 74 – 75 of the CQC’s 2024 Inspection Report
Publication Date:
13 January 2025
INQ0014962 – Pages 1, 12 and 14 of Risk Management Awareness Policy
Publication Date:
13 January 2025
INQ0108408 – Pages 7, 20, 34 – 35 and 37 of 2024 Child Death Guideline
Publication Date:
13 January 2025
INQ0014574 – Template Child Death Review Reporting Form (Form B)
Publication Date:
13 January 2025
INQ0014577 – Template Child Death Review Analysis Form
Publication Date:
13 January 2025
INQ0098714 – Appendix A1 to the Report from Picker titled The Thirlwall Inquiry Neonatal Staff Survey
Publication Date:
13 January 2025
INQ0098715 – Appendix B1 to the Report from Picker titled Sampling Handbook
Publication Date:
13 January 2025
INQ0098716 – Appendix C1 to the Report from Picker titled Trust level response rates
Publication Date:
13 January 2025
INQ0108782 – Table produced by the Inquiry Legal Team titled All of the Neonatal Deaths linked to the Countess of Chester Hospital in 2015 and 2016
Publication Date:
13 January 2025
INQ0108720 – Pages 1 and 5 of Implementation and Accreditation Framework from NHS Liverpool University Hospital NHS Foundation Trust titled SWAN A model for care for End of Life and Bereavement
Publication Date:
14 January 2025
INQ0002383 – Pages 1 and 25 of Report titled Gross negligence manslaughter in healthcare, The report of a rapid policy review
Publication Date:
15 January 2025
INQ0006755 – Page 1 of Screenshot of MBRRACE-UK’s data viewer titled Deaths within your organisation
Publication Date:
15 January 2025
INQ0014686 – Pages 1 – 2, 5, 7, 11 and 19 of Memorandum of Understanding titled Investigating patient safety incidents involving unexpected death or serious untoward harm: a protocol for liaison and effective communications between the National Health Service, Association of Chief Police Officers and Health & Safety Executive
Publication Date:
15 January 2025
INQ0002419- Guidance from the Nursing & Midwifery Council titled ‘The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates’, dated 29/02/15.
Publication Date:
17 January 2025
INQ0006466 – Page 3 of Policy from Countess of Chester Hospital titled Policy for the Reporting of Incidents
Publication Date:
17 January 2025
INQ0009277 – Page 1 of Paper from NHS England titled NHS Patient Safety Strategy Priorities for Leaders and Patient Safety Specialists
Publication Date:
17 January 2025
INQ0009278 – Pages 1 – 2 of Paper from NHS England titled NHS Patient Safety Strategy – Progress So Far
Publication Date:
17 January 2025
INQ0107008 – Pages 1 – 5 of Summary of Finding from NHS England relating to Safe and secure handling of insulin on neonatal units
Publication Date:
17 January 2025
INQ0108741 – Pages 1, 4 and 7 of Report from the Health Services Safety Investigations Body titled Recommendations But No Action: Improving Effectiveness Of Quality And Safety Recommendations In Healthcare, dates 16/09/2024
Publication Date:
17 January 2025
INQ0011609 – Exhibit SD/03 – Document titled Force Management Statement: Coroner’s Office
Publication Date:
20 January 2025
INQ0011610 – Exhibit SD/04 – Document from the Coroner’s Office, titled CO Guidance – Summary
Publication Date:
20 January 2025
INQ0011615 – Exhibit SD/09 – Document titled Reporting Deaths to the Coroner, Changes to the Reporting Criteria in Cheshire
Publication Date:
20 January 2025
INQ0108795 – Current pay scales for Chief Executives within NHS England
Publication Date:
22 January 2025
INQ0106946 – Expert Report of John Bowers KC
Publication Date:
24 January 2025
INQ0001888 – Draft Paper from the Countess of Chester Hospital titled Position Paper – Neonatal Unit Mortality 2013-2016.
Publication Date:
29 January 2025
INQ0007197 – Pages 137-139 and 165-167 of Bundle of documents for the GMC investigation of Ian Harvey
Publication Date:
29 January 2025
INQ0014171 – Countess of Chester Hospital’s Speak Out Safely (Raising Concerns About Patient Care) and Whistle Blowing Policy
Publication Date:
29 January 2025
INQ0014373 – Report from Dr Jo McPartland regarding a case review in relation to [Child A], [Child I], [Child O] & [Child P], undated
Publication Date:
29 January 2025
INQ0014962 – Countess of Chester Hospital’s Risk Management Strategy & Operational Policy
Publication Date:
29 January 2025
INQ0107983 – Exhibit VJ01, Curriculum Vitae of Dr Veronika Jiraskova.
Publication Date:
4 March 2025